Fi|-302 (Rev. 10-6-95)
FEDERAL BUREAU OF INVESTIGATION
DATE: 07-30-2010
CLASSIFIED BY UC60322LP/PLJ/CC
REAS OH: 1.4 ( c)
DECLASSIFY OH: 07-30-2035
ALL INFORMATION CONTAINED
HERE II IS UNCLASSIFIED EXCEPT
WHERE SHOOT OTHERWISE
ffillb
Date of transcription
09/15/2001
[ DOB: I I SSN : I
| NJ, home telephone [_
was interviewed at his business DEBELLIS INSURANCE
AGENCY, INC. (DIA) , 492 Franklin Avenue, Nutlev, N J 07 110. .
pres ent during the interview were I DOB : _
■ r n j r n
md I I NJ |
I DOB: SSN: I T After the
Ihome
Also
| | DOB: I | SSN: I | After the
identity of the interviewing agen t and the nature of the interview
was made known, I [volunteered the following
information: 7
is the
company was started by|
in 1967.
| | is the|_^
helps him out at DIA on occasion.
and does not work for DIA.£j*}
of DIA.
is a friend of
In June of 2001, a telemarketer from DIA contacted URBAN
MOVING COMPANY (UMC) to s olicit busines s . The telemarketer made an
appointme nt for | | to meet with a LNU on 06/Q6/2Q01.
was unable to meet in person so he spoke with | LNU on
the telep hone and w rote UMC a Commercial Auto Policy for tneir
vehicles. | | nnndn gt.pd all tip business with UMC via
telephone ana facsimile. I never went to the offices of
UMC. UMC is a household furnishings moving company. Cu^
recently received a check from UMC as payment
for their insurance. The check was drawn on account 1036500845365,
from CHASE MAN HATTAN BAN K. The check number was 8466 in the amount
of $3,463.37. I I provided a copy of the check and a copy of
all the documents in their files relating to UMC Cu)
remembered one male from UMC com ing to DIA to
pick up some driver ' s licenses of drivers for UMC. I did
not know the name of the individual, nor could he remember a
physical description.
Investigation on 09/14/2001 at Nutley , NJ
■b b by
frt
b/C
This document contains neither recommendations nor conclusions of the FBI. It is the property of the FBI and is loaned to your agency;
it and its contents are not to be distributed outside your agency.
FD-302a (Rev. 10-6-95)
Continuation of FD-302 of
09/14/2001
The writer showed
five males :
a photo array of the following
Photograph nu mber 1
| DOB:
Photograph numb er 2
I DOB:
Photograph
imber 3
DOB : r
Photograph number 4
DOB:
Photograph numb er 5
I DOB:
di d not reco gnize anyone from the photographs or
their names'. (Note : I I paused for quite some time while
looking at photograph number 3 .)
After looking at the photographs, asked the
interviewing agent if ev eryone at UMC was Israeli . The
interview ing agent asked I \ why he would ask such a question.
I I responded that he. also carries the insurance policy for
MOISHES MOVING COMPANY located near the entrance of the Hoboken
Tunnel . DIA has had the insurance for MOISHES for approximately
one year.£iO
| explained that the movers at MOISHES are all
subco ntractors . There are approximately 6 to 12 at any given
time. | | stated DIA carries separate insurance policies on
each subcontractor's business. The subcontractors are all y oung
individuals from Israel just out of the military. | stated
he knows this because* t hfi subcontractors talk openly aoout their
experiences. | | also stated the subcontractors seemed to be
all hard working nice individuals. Cu)
| has met all the subcontractors and employees of
MOISHES and knows them by sight . The subcontractors regularly come
into DIA's office to make payments and drop off any necessary
insurance documents.
DEBELLIS INS AGENCY, INC.
492 FRANKLIN AVE.
NUTLEY, NJ 07110
973-661-1500
FAX 973-661-9750
FACSIMILE TRANSMITTAL SHEET
TO:
COMPANY:
Urban Moving .
FAX NUMBER: ~ ' "
^ 01 - 55 %' 05 US
PHONE NUMBER:
FROM:
DATE:
09 / 07/01
TOTAL NO. OF PAGES INCLUDING COVER:
02
SENDER'S REFERENCE NUMBER:
be
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YOUR REFERENCE NUMBER:
WORKER'S COMP - RENEWAL
NOTES/COMMENTS: _ —
Please sign and return the enclosed form to my office naming me as your agent on the
worker's compensation renewal. There will be no difference in premium. I will service
this policy in conjunction with your commercial auto.
If there are any questions please contact me.
Sincerely,
at.T. U3FOBMA.TION COSTO
yniTHTETW IS BKCLASSIFIffi)
DATEJZ
R eceived :
1/11/01 4 : 25PM;
01/11/01 16:08 ©2oJ^P2 9434
201 662 9434 -> HP LaserJ^^3i oo; Page 2
' INSURANCE OFFICE W" DEBELLIS
&SQBD L AGENT/BROKER OF RECORD CHANGE
3l Vulley
Ofek Wft A. , h?5
I INSURANCE COMPANY NAUE
GS-O'I-O I
C.NA j“ms Co.
Please be advised that we wish to name A'v^W.y ^eftetRs floppy -j-h<l
c / PRODUCER V /
— as our exclusive representative effective Q^-rS
CODE# DATE
for the lines of business shown above, currently in force or submitted
by application.
This authorization replaces any other authorization that may have been
previously completed for any other insurance representative for the
stated lines of business.
JgfPlease rescind the day waiting period
□ There will be no rescission letter
INSURED'S .SIGNATURE
TITLE (IF APPLICABLE)
- MPANyAaME (IF APPLICABLE)
%
AC0RD 38 (1/98)
/a A/'nDn i^ADana ATinn
bDIAb
DeBELLIS INSURANCE AGENCY, INC.
492 FRANKLIN AVENUE, NUTLEY, NEW JERSEY 07110 • Tel: (973) 661-1500 • Fax(973) 661-9750
July 09, 2001
Urban Moving
3 18 th St.
Weehawken, NJ
Attn:| |
Re: Insurance Proposal
b6
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Dear | ~|
We spoke several weeks ago and I advised you that my firm would like an opportunity
to quote the insurance coverage for your moving company. I advised you at that time
that my office presently works with other moving firms both small and large.
The information I will need to obtain is as follows:
1. Copies of Policies (Auto, Cargo, Warehouseman Liability, Commercial
Package, Worker's Compensation, Commercial Umbrella)
2. Schedule of Vehicles (to include - year, make, model, VIN number, cost new,
GVW)
3. Schedule of drivers (name & license number)
4. Three years of loss runs from your current/prior carriers
If there are any questions please feel free to contact me.
SSSSMSm-
Sincerely.
IPPP . PREMI UM P AY M ENT PLAN -i
i ^sssssAfss Ti§£«5jaasa<w i ' Nm s sssassr' a SL3F~-~
Hi w»nt M Itemization® I <Jo not went on iumtortion
Total Premiums,
Cash Down Payment Required
Amount Financed (The Amount of
credit provided to me or on my behalf)
$ 38920. 1 00
$ 6730 |00
L5an agreement no. and/or QUOTE NO. =18.00
FINANCE CHARGE
(Dollar amount credit will cost me)
$ 28190 ,00
$ 1980 ,33
$ 31170 ,33
INSURED/BORROWER
(Name, Address and Telephone NUfUrer)
URBAN MOVING SYSTEMS INC
3 18TH STREET
WEEHAWKEN, NJ 07087
ACCT. no 4
Pm Phone No:
AM Phone No:
1 AGENT or BROKER (Name and Business Address) ]
PPP CODE
DEBELUS AGENCY
492 FRANKUN AVE
*
NUTLEY.NJ 07110
Phone No:
Fax No;
niinvm* i —
(Cost of my credit figured aa a ye arly ra t a)
p aymen t Sche d ,uj_e
16.00
%
Amount of
Each Payme nt
3463:37
Number of Payments Payable
— — — — — ..... ‘
Annual
~CTuiart 9rfj
lat ,
~^o nfHi'| Payme nt^!!
09/05/01
Final
Payment Dj
Q 5/05/02
PPP^PRBMIUM PAYMENT PLAN
Hudson CKyCsntto- Corner of Orwn & Stotost.
- ._j — ' ”, . rito pJumnnt A late charge will bo imposed on any installment which I
Prepayment I may prepay ,hB amount duounder this • NJ . madewithln five (5) days of the due data (10 daysjNJ. IN, TWI'and MS).
Kah anonXdVblo aenrice charge olllOtoCT. NY. PA $12 m NJ.oct made «Wn m» W ^ The , Bt& ^
*1$ in Rlend KY-.S 20 ln MD; 4^8 m ™n1mum of 0 * ^ (U0 0) ($2 in TN). See bach of form for mavlmum late
charga by state.
Contract Reference Reference should be made to the tenna of this
AflfMment as slated below and on the next page tor. informoHon about
nwpa^errt, default, the right to accelerate, the maturity of tha obligation,
and prepaymsnt rebates, and penalUea
Type of
Insurance
BA
BINDER
EMPIRE INS/
IN 1 12 i 08 I 06 | 01:
Taxes
it means tha Insured undersigned. . .. — « — • — — —
. _ t _ rtl
It means ma inBureo wkwiwbubu. ^ u* w, vou t 0 above Insurance comj>any<!e$>.
1 fayrnanw- "pSment Schedule." If I do not make any payments within flue (SJ days of the
Policy
Premiums
38620
00
0
00
0
00
38920
00
dale the payment la due, I will pay a
fciuinAnt* in c»nsioenauon oi 7 . .
. promise to pay you as stated above In the “Payment Schedule
tew* 1 8 |bnderetand the following: _ . . . Pniina* listed above this fee Is charged under Section 211? of the New York Insura
The insured understands ano ag rees ww 7271 ^.-^--.-- —
"NOTicE 1 . Do not' sign this Agreement bafore you reed It or if it oontains
tA any blank s pace. . — - —
, w JnRPn Tyou are entitled to a completely med]ry^yjOfto& A^ment,
JNgURE^ ■ .^hnrtaxl oftfcs* must sign; IT |
Ati Insured! mutt tlgn at named
capacity repres ents t ti at ilHntur^s hays au fl
ireof are inwpoime^w^^ -
TuSderthalaw.you have a right to pay off m ^ ‘S^ch^e
end under certain condition* t o obtain a partial refund : of the nnanc e cnargo.
of thla Agreem ent to protect your legal rig hto.
.h n ,,ui slan hi ouch: alenstotv edna In rapiwertaUvo'S
this transfldlon, — — — ---
fh^.rUjK^to^ lo tjaA^g^nto on the <tv»m **»•
| ($tcnature<*intiff*i)
m.
*nd TW* or *Q 8rrt wBfo>i*0
[EN^fe : FOR IMPORTANT INFORMATION
Oit*
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. .EOS 6^5
o> / ^ afiuj
n - ‘P - Bn w
* ju :Aa mao
DEBELLIS INSURANCE AGENCY, INC.
.492 FRANKLIN A V E .
NUTLEY, NJ 07110
973-661-1500
FAX 9 7 3- 6 6 1 - 9 7 5 0
r % \
FACSIMILE TRANSMITTAL SHEET
TO:
FROM:
1 1
COMPANY:
Urban Moving Systems
DATE:
08/01/01
FAX NUMBER:
TOTAL NO. OF PAGES INCLUDING COVER:
03
PHONE NUMBER:
SENDER'S REFERENCE NUMBER:
RE:
COMMERCIAL AUTO
QUOTATION - REVISED
YOUR REFERENCE NUMBER:
NOTES/COMMENTS:
Per our conversation today please be advised I have obtained the following quotation on
your commercial autos:
Liability Limit $1,000,000
Comprehensive & Collision Deductible $1,000.
Total Annual Premium = $3 8,920
Deposit Required to Bind = $9,730 (the balance of the premium can be financed on 9
monthly installments). Please make check payable to DEBELLIS AGENCY.
This indication is based on 6 units wilh total values of $237,995.
If there are any questions please contact my office.
Sincerely^
-/ -h J 22-
•b Coupon are enc
\c>sed c
u Ol
s ‘S&-&
tjr
PPP - PREMIUM PAYMENT PLAN
You have the right to receive at this time
an itemization of the Amount Financed.
” l want an itemization 3C I do not want an itemization
IPREMIUM FINANCE AGREEMENl f^D DISCLOSURE-STATEMENT
T Policy Designation (Check One) |x] Commercial □ Personal □ Assigned Risk
2 . Type of Agreement (Check One) @ New □ APC □ Renewal □ Inforce
3 preferred Billing Method (Check One) E Coupon Book □ Monthly Statement
LOAN AGREEMENT NO. AND/OR QUOTE NO.
A
Total Premiums
$ 38920 100
B
* a
Cash Down Payment Required
$ 9730 |00
C
Amount Financed (The Amount of
credit provided to me or on my behalf)
$ 29190 |00
D
FINANCE CHARGE
(Dollar amount credit will cost me)
$ 1980 |33
E
Total of Payments (Amount 1 will have .
paid after making all scheduled payments)
■$ 31170 133
D fjJP' I1D ™
* PPP“- PREMIUM PAYMENT PLAN
j. Hudson City Centre - Corner of Green & State St
° Hudson, NY 12534
R 51 8-822-1 000 * Fax 518-828-5729
16.00
INSURED/BORROWER
(Name, Address and Telephone Number)
URBAN MOVING SYSTEMS INC
3 18TH STREET
WEEHAWKEN, NJ 07087
ACCT. NO.
Pm Phone No:
AM Phone No:
AGENT or BROKER (Name and Business Address) ppp CODE
DEBELLIS AGENCY INFOBMATIOW COm ®
AOO PRANKI IN AVF tQ TTIJOI lASSnOklJ
( Y
492 FRANKLIN AVE UNCLASSIFIED,
NUTLEY, NJ 07110
Phone No:
Fax No:
ANNUAL PERCENTAGE RATE
(Cost of my credit figured as a yearly rate)
16.00
%
Amount of
Each Payment
3463.37
Payment Schedule
Number of Payments Payable
Annual | Quarterly! Monthly
1st
Payment Dilie
09/05/01
Final
Payment D|
05/05/02
Prepayment I may prepay the full amount due under this Agreement. It I Late Payment A late charge will be imposed on any installment j^ioh ii
do so, ttlere is a non-refSndable service chargeof $10 in CT. NY, PA; $12 in NJ;not made within ^©days^ MS).
I—.. i t_ jo / im tm* <tQn nnn_mfi inHnhip fpp This late charge will be 5% of the payment. The late charge win oe a
minimum of one dollar ($1.00) ($2 in TN). See back of form for maximum late
charge by state.
Contract Reference Reference should be made to the terms of this
Agreement as stated below and on the next page for information about
nonpayment, default, the right to accelerate, the maturity of this obligation,
and prepayment, rebates, and penalties
do so, there is a non-refondable service charge of $10 in CT, ny, ha; in Nj;noi maae wun.n ..v« ™
$15 in Rl and KY* $20 in MD* 4% - $15 maximum in TN; $30 non-refundable fee This late charge will be 5/o of p^ment. The late charge will be a
included in finance charge in'lN. No refund of unearned interest will be made if minimum of one dollar ($1.00) ($2 in TN). See back of form for maximi
the amount refundable is less than one dollar ($1 in NY, NJ, MD) and three
dollars ($3 in CT, PA, Rl), or maximum allowedly state.
Security Interest As a security for the payments to be made, I am assigning
to you all unearned premiums under the Policies, and all loss payments
which reduce the unearned premiums. This means that this money can be
used to pay amounts due under this agreement.
SCHEDULE OF POLICIES: Personal Auto - Bl (Bodily Injury) - PD (Property Damage) - HO (Homeowners) - F (Fi re) - ML (Multiline) - MC (Motorcycle) - BOP (Bus iness Owners)
— — 1 1 _ .. . . i I /m\ T/mnI Term .. ~ . I — .
Type of
Insurance
BA
Policy Number
and Prefix
Full Name of Insurance Company and
Name and address of General Agent or
[Company Office to Which Premium is Paid
BINDER
New (N)
or Renewal (R)
Policy — >
EMPIRE INS/
(N)
or
(R)
N
Term
In Mos.
Cov. by
Prem.
12
Effective Date
Mo. Day
Yr.
08
06
01
Taxes
Policy
Premiums
38920
38920
00
00
00
00
Wherever the word "Policy 11 is those things listed above in the Schedule of Policies. Whenever you is use jjFees
inthis Agreement, it means PREMIUM PAYMENT PLAN (PPP). Whenever the word "I" (or) "me" is used in this Agreement,.^, Premiums
it means the insured undersigned. . ^ I (Record to " A ") , .
■■■
charge as stated above.
‘ g- ^ =SS55SSS5g:
NOTICE
TO
INSURED
red understands and agrees tnat tne provisions on me icveiac aiuc ..
1. Do not sign this Agreement before you read it or if it osteins
any blank space.
3. Under the law, you have a right to pay off in advance the foil amount due
and under certain conditions to obtain a partial refund of the finance charge.
9 You are entitled to a completely filled in copy of this Agreement.
4 Keep your copy of this Agreement to protect your legal rights.
__± ut~ eHrtiitH eirm sc cnr.ir sianatorv actina In representative's
Mil msuieufc lliusi aiyu as uameu t'wxvww. •• — , P - .
capacity represents that all Insureds have authorized this transaction.
By.
Tho i tnHfarctnnprj AnenLnr Broiwagrees to the Agggn^ts on the reverse side. ; b6
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Date
Jg)-
(Signature of Insured)
— (Signature and Title of Agent or Broker)
Date
wnTirFHSfcF NEXT PAGE FOR IMPORTANT INFORMATION
ECS 5/95
From:
URBAN MOVING SYSTEM
3 18TH STREET
WEEHAWKEN, NJ 07087
I I
Place stamp here
Attn: Process Immediately
PREMIUM PAYMENT PLAN
HUDSON CITY CENTRE
CORNER OF STATE & GREEN STREETS
P.O.BOX 668
HUDSON, NEW YORK 12534-0668
(Fold with the above facing out for mailing)
Premium Payment Plan
PO Box 668, Hudson, New York 12534-0668
Dear Insured:
Welcome! It can take over a week to receive your payment coupon book. This is your first payment coupon. To avoid
late charges, your payment must be received by PPP on or before the due date. Payment to your agent or broker
does not eliminate the late charge. MAIL EARLY!!
The easy way to get and keep your needed insurance coverage, finance your policies with Premium Payment Plan,
easy and flexible payment schedules with low down payments to help you afford the best protection available.
Why should you deal with multiple bills for each insurance company? Finance all your insurance and pay only one bill
each month. PPP is here to serve you through the best professional independent insurance agents and brokers in the
country.
Call us at PPP if you have any questions (518)822-1000
(For mailing, fold-up the below section -place check in the fold - tape or staple all 4 sides)
FIRST PAYMENT COUPON:
Insured's Name*. URBAN MOVING SYSTEMS INC
Address: 3 18TH STREET
WEEHAWKEN, NJ 07087
Due: 09/05/01
Amt Due: 3463.37
Agent/Code: * DEBELLIS AGENCY/
Premium Payment Plan * PO Box 668, Hudson, NY, 12534 * Tel. 518-822-1000
08 - 10-91 S 3 J . -86
m. 10. 200 i
i-.iim «
[tUKU lNbUlWIUiult Ins.
ID =
Eff: 03 / 01 /
/IT98
Vehicle
Vehicle Type
Class Code
Liab Factor
?hy Dam Factor
Territory
Cost Netf
Age Group
r 2000 CMC Van : 1399 Incarnations! .•
T . ^ +
: Truck
- Not otherwise ^Clas
: Truck
: Not Otherwise Clas
= 03199
: 1 . 30 + 0 . CO - 1 . 30
: l- 10 rO.OG«l.io
: 10 si
: $ 18,000
~ 2
— +
33199
: 1,55+0.00=1.55
: 0.80-r0.0O*G,8O
: 10
: $35,000
: 3
Coverage
Liability
Medical Pay
PIP
DM
Coverage Type
Other Than Cal
Collision
Premium
: Limits : Premium : Limits Premium
■ — + „
: $ 1 , 000, 000 $ 2543 . 0 D;$ 1 , 00 Q , 000
:None 50 . OOiNcne
; Pedestrian 0 . 62 : Pedestrian
:$1, 000,000^ $216.00:51,000,000
: f? It 'nAA h ? 1Sive : Comprehensive
f e<3 sl4l -00'$l/000 fled S138.00
: $1,000 ded $345. 00: SI, 000 ded $401.00
5 $3245.62: $3774.62
"* “ — — - — .....
$3019.00
$ 0.00
0.62
$216.00
<3
PQ 1/81
*
Total innual Premium ; S 7 , 020.00
-kx % 33 .q
98-10-81 92:27 TO:
FROM:
P 83
/vt.T. JNFOHMA.TT 05 T COM!AItJED\
HEREIN IS IMCLASSIOT) , . A /, _
DAT E Vpy/6< B V fa VJ/to c fA/Y/:
AUG 10 2001 12:32PM HP^uRSER JET 3200
New Jersey Headquarters
■3, 18“' Street
-Weehawken, NJ 07087
(201)558-0031
Urban Moving Systems, Inc.
New York Headquarters
446 West 50 ,h Street.
New York, NY 10019
(212) 338-9267
Debellls Insun
VIA FACSIMILE: 973-661-9750
The informaion you requested Is-below. Please call me to confirm that you received them and that the application is on it's
way.
Urban Moving Systems, Inc.
MC 320465
NYS Dot t-33739
US Dot 691256
PC 0076006
MC 398463
USDOT 923345
8-lo -oi
)ease w ne. cop 1
<2.s o"f all ueLic/e
rejlsk^ns as Soon as -possible,
/M.T. INFORMATION CONTA3
HEREIN/iayO^C^SIITED
Co-5 "TW-fdr
Ref:
For Review n Please Comment n Please Reply n Please Recycle
ccpp -ruA-s _ f^lVn j
(X^e. or'i-^rei. fttcouycf” Sold cd"
$ 9l30 received. k)eed hound
8~5~0\ or §~G>-61. ^Tficmks.
ALL INFOEMA.TION CONTA335EO»i
ISMSIP GLA S Sincerely,
MT M
ACORD COMMERCIACTNSURANCE APPLICATION
APPLICANT INFORMATION SECTION
IK3I&&9IVZ
IVnfnwISSTTinS
973)661-1500
FAX 073)661-9750
DeBellis Insurance Agency, Inc
492 Franklin Avenue
Nutley, N) 07110
0ATE
08/03/2001
Inter-America Ins Agency
POLICIES OR PROGRAM REQUESTED
CA
AGENCY CUSTOMER ID
00007675
STATUS OF SUBMISSION
INDICATE SECTIONS ATTACHED
PROPERTY I
GLASS AND SIGN
ACCOUNTS RECEIVABLE/
VALUABLE PAPERS
CRIME/MISCELLANEOUS CRIME
EQUIPMENT FLOATER
INSTALLATION/BUILDERS RISK
ELECTRONIC DATAPROC
COMMERCIAL
GENERAL LIABILITY
GARAGE AND DEALERS
VEHICLE SCHEDULE
BOILER & MACHINERY
WORKERS COMPENSATION
UMBRELLA
TRANSPORTATION/
MOTOR TRUCK CARGO
BUSINESS AUTO ^
MOTOR TRUCK CARGO 1 I TRUCKERS/MOTOR CARRIER
PACKAGE POLICY INFORMATION
ENTER THIS INFORMATION WHEN COMMON DATES AND TERMS APPLY TO SEVERAL LINES. OR FOR MONOUNE POLICIES.
PROPOSED EFF DATE PROPOSED EXP DATE BILUNG PLAN | PAYMENT PLAN | AUDIT
08/06/2001 08/06/2002 — D,RECTB,LL
' X AGENCY BILL
MAIUNG ADDRESS 1NCL Z1P+4 (of First Named Insured) HUDSON
3 18TH STREET
WEEHAWKEN, N3 07087
H NOT FOR PROFIT BUSINE^TARXED
organization 1990
ACCOUNTING RECORDS CONTACT
PREMISES INFORMATION
LOC# BLD# STREET, CITY, COUNTY. STATE, ZiP+4
\ 3 18TH STREET
0000100001 HUDSON
WEEHAWKEN NJ 07087
CITY UMITS
INSIDE
OUTSIDE
INSIDE
OUTSIDE
INSIDE
OUTSIDE
OWNER
TENANT
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS BY PREM1SE(S)
MOVING & STORAGE (HOUSEHOLD)
flf.T. INFOEMATIOW
fSPSBSa*SSS,uhti
GENERAL INFORMATION
EXPLAIN ALL "YES*’ RESPONSES
1. IS THE APPUCANT A SUBSIDIARY OF ANOTHER ENTITY OR DOES
Z IS A FORMAL SAFETY PROGRAM IN OPERATION? ■
3. ANY EXPOSURE TO FLAMMABLES, EXPLOSIVES, CHEMICALS?
4. ANY CATASTROPHE EXPOSURE?
5. ANY OTHER INSURANCE WITH THIS COMPANY OR BEING SUBMITTED?
6. ANY POUCY-OR COVERAGE DECUNED.C^ CELLED OR NON-RENEWED
REMARKS
i hs rni i
“TOI
io
la
IB
IBI
EXPLAIN ALL "YES H RESPONSES
7. ANY PAST LOSSES OR I CLAIMS RELATING TO ' S^UALABU SE OR
8. DURING THE LAST TEN YEARS, HAS ANY APPUCANT BEEN CONVICTED
OF ANY DEGREE OF THE CRIME OF ARSON? (In RI, this question must be
answered by any applicant for property Insurance. Failure to disclose
the existence of an arson conviction Is a misdemeanor punishable by a
sentence of up to'one year of Imprisonment).
9. ANY UNCORRECTED FIRE CODE VIOLATIONS?
—
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE
ppr^hn fii pq aw APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY IWATERIALL
f a IM FOR W! ATI ON OR CO N C EALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING
ANY FACT MATERIAL VhERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND
SUBJECTS THE PERSON TO CRIMINAL AND FNY: SUBSTANTIAL! CIVIL PENALTIES, :
APFUCANTS
SIGNATURE
ACORD 125 (8/97)
PRODUCER'S
SIGNATURE
PLEASE COMPLETE REVERSE SIDE
©ACORD CORPORATION 1993
PRIOR CARRIER INFORMATION
TOTAL PREMIUM
LOSS HISTORY
ENTER ALL CLAIMS (REGARDLESS OF FAULT) OR OCCURRENCES THAT MAY GIVE RISE TO CLAIMS FOR THE PRIOR 5 YEARS (3 YEARS IN KS & NY)
DATE OF
OCCURRENCE
LOSS SUMMARY
REMARKS NOTE: FIDELITY REQUIRES A FIVE YEAR LOSS HISTORY
NOTICE OF INSURANCE INFORMATION PRACTICES ^ , „ ,
PERSONAL INFORMATION ABOUT YOU MAY BE COLLECTED FROM PERSONS OTHER THAN YOU. SUCH INFORMATION AS WELL AS OTHER PERSONAL
AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT
YOUR AUTHORIZATION. YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND CAN RE <^J=STO^
INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING SUCH INFORMATION IS AVAILABLE UPON REQUEST.
CONTACT YOUR AGENT OR BROKER FOR INSTRUCTION ON HOWTO SUBMITA REQUESTTO US.
[•];!»]
ACORD®
producer IJW pxtJ . (973) 661-1500
FAX ' (973)661-9750
DeSellis Insurance Agency, Inc.
492 Franklin Avenue
Nutley, N1 07110
CUSTOMER ID: 00007675
applicant URBAN MOVING SYSTEMS INC
(First
Named
Insured)
EFFECTIVE DATE . EXPIRATION DATE 0IRECT3ILL
08/06/2001 I 08/06/2002 X agency bill .
DATE (MM/DD/YY)
08/03/2001
PAYMENT PLAN
FOR
COMPANY
USE ONLY
I- <3
■1MB
COVERAGES ! COVERED AUTO SYMBOLS
. COVERED AUTO SYMBOLS
PERSONAL INJURY
PROTECTION
ADDITIONAL
P.I.P.
OR EQUIVALENT
NO-FAULT COVERAGE
DEDUCTIBLE
MEDICAL
PAYMENTS
UNINSURED
MOTORIST
UNDERINSURED
MOTORIST
HIRED/BORROWED iWl
LIABILITY !
NON-OWNED
LIABILITY
TOTAL
W/C
$
$
M/E
$
EACH PERSON
$
X j CSL !
T&l
EAPER
$
1,000,000
B! EACH ACCIDENT
$
PROPERTY DAMAGE
S
X ; csl |
Bl
EAPER
$
1,000,000
Bl EACH ACCIDENT
$
PROPERTY DAMAGE
$
COST OF HIRE
:
< i
IF ANY BASIS
$
GROUP TYPE
! EMPLOYEES
j VOLUNTEERS
i PARTNERS
HIRED
PHYSICAL
DAMAGE
COVERAGE IS:
SECONDARY
(4) OWNED AUTOS OTHER THAN PRIVATE PASSENGER
(5) ALL OWNED AUTOS WHICH REQUIRE NO-FAULT COVERAGE
(6) OWNED AUTOS SUBJECT TO COMPULSORY U.M.IAW
(7) AUTOS SPECIFIED ON SCHEDULE
(8) HIRED AUTOS
(9) NON-OWNED AUTOS
COVERED (l)ANYAUTO (4) uvvncu nu i uo u i ncn i iwn rravni c r/\oocnucn (f;nuiuo orcuint
AUTO (2) ALL OWNED AUTOS (5) ALL OWNED AUTOS WHICH REQUIRE NO-FAULT COVERAGE (8) HIRED AUTOS
SYMBOLS (3) OWNED PRIVATE PASSENGER AUTOS (6) OWNED AUTOS SUBJECT TO COMPULSORY U.M. LAW (9) NON-OWNED AL
UST ALL DRIVERS, INCLUDING FAMILY MEMBERS THAT WILL DRIVE COMPANY VEHICLES, AND EMPLOYEES WHO DRIVE OWN VEHICLES ON COMPANY BUSINESS.
DRIVER: ’ . , . , r j : YEAR : DRIVERS UCENSE .NUMBER/
NAME (Include address, If required)
j OBTAINING MVR S
CITY, STATE, ZIP
WHERE GARAGED
GVW/GCW
CLASS
15000
ADD L PIP X MOTOR
\ F
. „ TOWING
1 FT
MED PAY & LABOR
aillil
1,000 COLL
.make: INTERNATIONAL
00002 1999 modelTRUCK
SYM/AGE ' COST NEW
CITY, STATE, ZIP
WHERE GARAGED
DRIVE TO WORK/SCHCQL USE
UNDER IS MILES :
IS MILES OR OVER I
. . . J yjrN.t XHTS CAAM 5X675087
’ TERR " : GVW/GCW ‘ CLASS
! 2B000
CHECK
. COVERAGES
X j LlAB
X I PIP j
make: INTERNATIONAL
00003 1994 — ^
: Anm em Y UNDRINS
; ADD L PIP A MOTOR
j MPn DAV TOWING :
; MED PAY 4 LABOR :
UNINS SPEC !"
: MOTOR C OF L :
: BODY “
„ :* 42,259
: SIC FACTOR SEAT CP RADIUS FARTHEST TERM
LSP DEDUCTIBLES ACV X COMP £ ? £\
X COMP ■ : AA | X ' ST AMT :$ 1,000
X COLL js 42,259 I s i760Qcqll[
CITY, STATE, ZIP
WHERE GARAGED
VEH# ; YEAR MAKE* FORD
00004. 1993 '
CITY. STATE, ZIP
WHERE GARAGED
J.Y^..MSPPPN9RH559152
GVW/GCW CLASS
23000
Ann -I did v O N DR1NS j T’
ADD L PIP A MOTOR : = F
MED PAY 4 LABOR * : FT
UNINS SPEC : :
MOTOR C OF L : : FTW
make; FREICHTLINER
modeuTRUCK
CITY, STATE, ZIP
WHERE GARAGED
vj.n„* 1FDNK72CXPVA20054
GVW/GCW CLASS
18000
7nm
ADD L PIP A MOTOR : :F
Mcn D . v TOWING \ 1 _
MED PAY 4 LABOR : * FT
UNINS SPEC \ I
MOTOR C OF L : : FTW
BODY “
E:
vm: 1FVABPAL91HH68277
GVW/GCW CLASS
25500
SIC . FACTOR : SEAT CP: RADIUS FARTHEST TERM
: DEDUCTIBLES
X j COMP
X j COLL
comp"
< j ST AMT ; $ 1,000
15,000 fs l a " 000 coil
! SYM/AGE ! COST NEW
ann^'oiT* FU*
ADD L PIP A MOTOR : F
MPn DAV TOWING : 1 _
MEDPAY & LABOR : | FT
UNINS SPEC : 1
MOTOR C OF L : • FTW
EXPLAIN ALL "YES’* RESPONSES
1. WITH THE EXCEPTION OF ENCUMBRANCES, ARE ANY VEHICLES NOT SOLELY
OWNED BY AND REGISTERED TO THE APPLICANT?
Z DO OVER 50% OF THE EMPLOYEES USE THEIR AUTOS IN THE BUSINESS?
3. IS THERE A VEHICLE MAINTENANCE PROGRAM IN OPERATION?
4. ARE ANY VEHICLES LEASED TO OTHERS?
5. ARE ANY VEHICLES CUSTOMIZED, ALTERED OR HAVE SPECIAL EQUIPMENT?
6 . ARE ICC, PUC OR OTHER F1UNGS REQUIRED?
DESCRIPTION OF GARAGE/STORAGE LOCATIONS
NO • 7. DO OPERATIONS INVOLVETRANSPORTING HAZARDOUS MATERIAL?
8 . ANY HOLD HARMLESS AGREEMENTS?
9, ANY VEHICLES USED BY FAMILY MEMBERS?
IF SO, PLEASE IDENTIFY IN REMARKS.
10. DOES THE APPLICANT OBTAIN MVR VERIFICATIONS?
11. DOES THE APPLICANT HAVE A SPECIFIC DRIVER RECRUITING METHOD 7
1Z ARE ANY DRIVERS NOT COVERED BY WORKERS COMPENSATION?
13. ANY VEHICLES OWNED BUT NOT SCHEDULED ON THIS APPLICATION?
MAXIMUM DOLLAR VALUE SUBJECT TO LOSS
DO NOT USE IN AR, AZ, CA, CT t DE, FL, GA, LA, IL, MD, NJ, NV, OK, OR, PA, Rl, SC, WV; USE SPECIFIC STATE SUPPLEMENT. MINIMUM UM LIMITS REQUIRED IN DC, ME, MN, MO, VT, VA, WA, WI.
SELECTING UM AND UIM LIMITS EQUAL TO MY LIABILITY LIMITS,
SELECTING UM AND UIM LIMITS LOWER THAN MY LIABILITY LIMITS, OR
REJECTING COVERAGE ENTIRELY.
I UNDERSTAND THATTHE COV- 1. 1 SELECT UM AND UIM LIMITS INDIC IN THIS APP (APPLICANTS SIGNATURE)
2 * 1 REJECT UM B0DILY ,NJURY COVERAGE (APPLICANTS SIGNATURE)
APPLY TO ALL FUTURE POLICY 3. 1 REJECT UIM BODILY INJURY COVERAGE ‘ (APPLICANTS SIGNATURE)
CMNG^ 4 * 1 REJECT m PROPERTY DAMAGE COVERAGE 1 (APPLICANTS SIGNATURE)
OTHERWISE IN WRITING. 5. 1 REJECT UIM PROPER^ . v wyy .. vw „ v .. vv ... (APPLICANTS SIGNATURE)
I UNDERSTAND AND ACKNOWLEDGE THAT UNINSURED MOTORISTS
(UM) AND UNDERINSURED MOTORISTS (UIM) COVERAGES HAVE
BEEN EXPLAINED TO ME. I HAVE BEEN OFFERED THE OPTIONS OF:
PR0DUCER ^jS^""C973) 661-1500
FAX " (973)661-9750
DeBellis Insurance Agency, Inc.
492 Franklin Avenue
Nutley, NI 07110
CODE:
AGENCY-CUSTOMER ID • \
00007675
^.|^E|DESCRISld.«
VEH# ; YEAR : MAKE: INTERNATIONAL
applicant URBAN MOVING SYSTEMS INC
(First
Named
Insured)
DATE (MM/DD/YY)
08/03/2001
EFFECTIVE DATE EXPIRATION DATE
08/06/2001 | 08/06/2002 x
PAYMENT PLAN
AGENCY BILL
FOR
COMPANY
USE ONLY
00006 2001;
COMML
RETAIL
SERVICE
GVW/GCW
CLASS
ADD'LPIP
UNDRINS :
MOTOR ;
j F !
MED PAY
""TOWING :
& LABOR :
1 FT ;
UNINS
SPEC i
1 FTW i
W.VVVV,VftV.:
MOTOR
COFL :
V'-AV.VA'AV.V. V.V.'
SEAT CP! RADIUS = FARTHEST TERM
Ifl
page 61
„ . ciisto® flPEf 0S£B REf &r au now** '** ^
VANUNtt' INSWAHCCCOHPJKV ^ m > 1 5
mm ■ . CU5T . type: < ***1 . BUri
TIH£ 201 POLICY DATES «/«/* JjJjycA t Oft., 1HC.
CUSTOHEH l«C> M. BOX £» fr iWO
•RSrtSflT ** a
-r HW! - s& *- ..
• . . &» »s..^ —
Ml “®"
ratten . 7. •) cmbbml IW* gnoentU ,„J I,II, o.w t,W ,«, wi(,n
sawwfe" **■■■£■ -dr - .
foLKJ JEW! W 0J CBHHERCUL AUTO jbbctiKX ’{f '°° 0,00 1 0,00 . „ 1610.25
0 RESERVES, • 0.00 o fl0 «••»
COVERAGE "“* OPEH- m 1510,25
1 RESERVES 0 ‘ M ‘W***-^^*
closed o.oo l8,z7>B2
tS<<<c: 3s«< s = ss: “ iM,esi ' 5 claihs >0600 .00- 15 tf'i27.02
rfltMM POLICY , ***** • * 2
ffl o
E "h
0. $ M
w 2 3
; «>
0 " *
YAGE 5E
MM jegsg? • SKT“ “S' * M “ 1 “ TE “"'*
* HU* OATES mt» m ^ wm** t Cttt ( I(IG>
J12 MVONIA AVENUE |1 ( HAHHASSETT
JERSEY jO! TV ' HJ ° W2
S' !! wiS’ *“"!,» „» imt mie '*■ * : g; BS S
W-I2WS9
07 / 01 / 9 ?'
'CLWHI
C|MT n
CIHT I )
clht in
clht I 5
aMTf«
SS“"* »/w/»
j ■<• 28 * « J<1W
ICTION OTHER TYPEWS ^ _ a|/pD LIABILITY
i M l I -1 “f”
or 1 .... Mik i Uf Q
W mi ura
KLj®meu»
cuff #r
ttHEffl
rt.nr uri 1
CLHT IN
CLHT #5
0LHU6 «
SJU1 ««3M3»s4
09/1.1 /W I
CLHT fl |H
CLHT #2 1
CLHT |1
curt M
CLHT 15
CLHT It
™ !ffi!
NEHVOBK HY 06100
0 61 LOSS - BI/M} L1{J|H5
6 P6 LOSS ■ m LlAltUTY
m, oo
10600.00
U^HV I 0 ~
670.00
11210,50
11230.50
0.00
l 00 21)11.41 hA no
CLOSED 10/07/99 J' 40.00 J 'QO j
7u£t IIP* NJ 07000 J'S 2N51.NI 2453.41
is3H= _ s=a - cM » s «« a - m
] . Min NJ 07000
iiP^ WT ' HI ?SDLOSS-Bl/rt UABIUW
CLHT 15 «« =sW ^^ g S * MK8 M « 25 1610,25 04
CLW |t , n , 9 t/M 0,00 1 "'® , 2 6.00 ....
^ S ^j 0lS ' K»H HJ 07000 0.00 U10 ; 23 1610,25
WWW, LjIT UUILUIHg rnmsl0H
CLHT |l URBAN H0VIH5 SYSTEMS, IHO,
ClHt #2 1
CLHT |J
CUIT IN
CLHT #5 _ , ; ,
08/01/0**
mm m , ' mSmvT 10 "m «
TIME »:»!«? N$r. WE. N 8 S H£ pJ tl >oflcV NUMBER; M0B5JJM
toman* t »., ik.
OQOtlO?Z518 WBAN H6VIW SV5TCH3, INC, r BOX m w , 1nM m
)ia PAVOHIA AV£HUE #f HANHASSETT » IH»« »»
JERSEY CITV HJ
8 ACE 6 ,
DATE 07/31/00
total ' JSSlfiLF Kvep Sored
open nmm deonkidle bbwm *
reserves ’mm \»
•«•■***
tSiALS 01 COHHERC'At. AUTO ,o00.00 0 fl0 O.04 ^
C0V £ 0«ETVPE:C0ltl S IOj ER |W O.Cfl 0.00 ^ 0. ^
CLOSED 2 BKKVES 75 ’7«,50
0E0UC7ISLE 0,00 ^ 0-OD «**■*>
CoWEtyPEtBl/fOlljOlLlTV 0> °°
l RfSEDVCS 0.44 O’ 00 0,1,0
CLOSED 1 R Ed _ 0,00 .^ ^BBwawaB
■ r r rWnrt ..M,H iuw:::n«« ;! ^ li,xl!t>3
“ oc0 0,00 7155,10
»<MK AA Irt&f! Qfl V*UV
•TOTAL FOR POLICY NllfflEB &fl0Z25<M0 , 2CLAIH1
10W.90
7K5.1D-
• *
o
a
s
L
<Ts.
. **
E
®03
tfl
•tf)
WH
I N«
1 5Ju
N ft*
w
• h
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<r ..
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5
gg
H
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s o
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CM H
\ 0
CO \
O CO
o
vmlimr insurance *mw • .® T “^i?^ CLW£ ° ^Sar mbs oooooooo
sSU* *.<**
SSlS^W«' INC. £ BOlUfli
J 12 PAV 0 NU JWEHEI 1 HAHHKSETT
JERSEY Cl TV N
DATE 07/1 l/W
KV HOW MOB
. l.o.I. OICIIWMW tUIN SIMM KW1M1S ra »'
ffiT SSU»* mmmm
LOSS BRlt .«* nt CLAIM
as- S 8» " S.
TOTAL ID. INC. mm
TOTAL IN. W*
m«m total pa - ;: — ~
— ■“"* fl on 0.00
0,00
0,0
o.o
0,00
76.50
76.50
0.00
76,50
76,50
0.00
76,50
OfSC. OF CLAIM -
c closed mm
,,-122230 * MlJfiiM 1HC * ELIZABETH NJ 01000
W* MW
CCOLlls,wl
CLHT fl '
GLUT jfJ
CLHT 15 ^^^^ auss£U9SSS 'fT ^000 00 M
*3 55 B3 70M.60
59-122955 1 ELIZABETH HJ 07000 96N.N0
WWM VnHCP" 1 * E # 1 S U(k - n/f» lusiLin •
tar HI J
CLHT ti
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PAGE 59
DATE 07/31/M
TOTAL NET
KECOVEBED IK*'
i T^rii POTEKTIAL
0?EH Mnan kmctibie
RESERVES IN* W
**’■'-*
%iS STJ.i P.BREB? 1, *"* » ,BLE ooo * «• •• w 4,04
CoVERAOE WEi BI/PO UABIt-'H „ RESERVES ^ °'o,00 fl ^ fliflD 14M.T8
CLOSED 2 RK0,VB
'^^u**^'*^^***™" ■■ 0 00 0.00 ML * 1
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mee.fa
total for P 0 LlflV*BMM 5 Hi»
| CLAIMS
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TUB M:aa [TS/SX NO 7LS81 ®««
PAGE 5*
DATE 07/11/®®
PAGE X
rssr st wst' B »«— •
TlH£ 20:19:27 WIST, TYPE,. I poR POLicY KUHKER! BM2Z5IM®
pcuwoatko
MEHUfflERAKO jAHt! . 135 A.E. COEfTlWWI k 1«.
Mtoritew <mah moving svstehs, w. ? ,o, box «oe H 11o30 43W
ili pavohia avenue ft habhassett NV 11030 0MO
JERSEY CITY NJ mi
niNPAlVOI WU* IH5I1MHCE COHPAHY trcOYIRY
1,0,8, 01 COMMERCIAL AUTO ' CLAIH STATIIS REPORT DATE OPEN l®» [[[’ [jjjj S In! W.
™'g°> $Smm m «■» l#WT1M mimm total paid
-=r -a “
90-711837
07/0/M
CLOSED
JERSEY CY
10/07/98
HJ 07000
“*• c r» LOM - n/» Li»iun
1488,78
0,00
1408,70
1408,70
0.00
1488.78
— uiai mtaa^w 31 ^
JUL 12 2001 3:22PM
H^-flSERJET 3200
New Jersey Headquarters
3, 18 th Street
Weehawken, NJ 07087 ^
■•(201)558-0031 •' \
09-1 ST
Urban Moving Systems, Inc.
New York Headquarters
446 West 50 w Street
New York, NY 10019
(212) 338-9267
DeBellis Insurance Agency, Inc.
VIA FACSIMILE: 973-661-9750
Re: Insurance proposal
UCQJ I I
Please review the fallowing and call me to let me know if you need anything else.
Thank you,
C s/93-
•p.t> = *17. -- $ 6.^06 + 3 %
iioo
4 *3o OueVe
- "Bor
CPKG - Bo-R
V/C - B&R
ALL mFOBMATLOn CONT.
HEREIN
B
JUL 12 2001 3:22PM HB^-RSERJET 3200
08/25/01 MON 14:38 FAX 1 8lWW2 9200 BSC
P-2
@001
Baldwin Sadler Corporation
dba-CA*Baldwin Sadler Insurance Services
National Managing Speciality Underwriters
CA License OBul 356 ..
June 25, 2001
I
cJol-SSV- 04!S~
urban Moving Systems, Inc.
3 18TH STREET
WEEHAWKEN, NJ 07087
PQ Box 7001
•Royersford.PA 194BB-0841
(610)792-9100 (800)227-9040
(610)792-9200
Re: Urban Moving Systems, Inc.
(IHZ5623720; 16-AUO-OOto 16-AUG-01)
Dear
be
b7C
Baldwin Sadler Corporation is a national managing specialty underwriter for
cargo insurance for The Hanover Insurance Company.
We have had no reported claims on the above captioned policy as
of June 25, 2001 . r .
Sincerely,
COPY
7
JUL 12 2001 3:22PM
^LASERJET 3200
Transmit . txt
1 PAGE
LOSSES AS OF: 06/30/2001 ACROSS ACCOUNTS - BY ACCOUNT
RUN DATE: 07/05/2001 RMD DETAIL LOSS RUN
INSURED : URBAN MOVING SYSTEMS INC PRODUCER: 0004 J REPORTING OFFICE: 0
J
POLICY NUMBER: UB 688X6573 ACCIDENT PERIOD FROM: 01011990 TO 070520
CLAIMANT ACCIDENT 0/ CLAIM
INJURY CLASS FILE NUMBER
DATE C AMOUNT
CODES CODE ADJ PRE- CLAIM
POLICY EFF. DATE: 09/18/2000
NO CLAIMS FOR THIS POLICY PERIOD
STATE:
MEDICAL
AMOUNT
* TOTAL STATE NO. CLAIMS
OPEN
... " CLOSED
*TOTAL POLICY NO. CLAIMS
LOSSES AS OF: 06/30/2001 ACROSS ACCOUNTS - BY ACCOUNT
RUN DATE: 07/05/2001 RMD DETAIL LOSS RUN
Injury Code:
r of fRe'"
D-Death
nder which the
P-Permanent Disability
compensation
M-Major Permanent Disability
N-Minor Permanent Disability
T-Temporary Total or Temporary Partial
ave 0000 until
X-Medical Claims
Eff Date
7- Contract Medical or Hospital
8- Closed Death Cases in CA
Page 1
Class Code: The code numbe
manual classification u
employee is covered for
Prefix CM claims will h
18 months after Policy
JUL 1:2 20.01 3:22PM
.LRSER JET 3200
Transmit . txt
9-Permanent Partial not in CA, TX, or NJL
0-Hospital Reimbursement in CA
0/C - Open or Closed Indicator
1 PAGE ' 1 ’
Selection Criteria for: 01-RMD DTL LOSS RUN
Member Name:Q6360Q01 . Run-Time: 15. 57 . 36
Parm Name: Parm Desc:
IF ACC_DATE FROM 01011990 TO 07052001
IF POL_NBR EQ 688X6573
Format: 0
^Current or History Selectipn was: C
“The Type of Dollars Reported was:
Claim Size Option:
Report Title — >
Sort Fieldl: Heading:
Sort Field2: Heading:
Sort Field3: Heading:
Variable Selection Statements:
>
Page 2
be
b 7C
COMPANY: DATE:
Urban Moving Systems 08/01/01
FAX NUMBER:
TOTAL NO. OF PAGES INCLUDING COVER:
01
PHONE NUMBER:
SENDER’S REFERENCE NUMBER:
RE:
YOUR REFERENCE NUMBER:
COMMERCIAL AUTO
QUOTATION
NOTES/COMMENTS:
Per our conversation today please be advised I have obtained the following quotation on
your commercial autos:
Liability Limit $1,000,000
Comprehensive & Collision Deductible $1,000.
Total Annual Premium = $40,292
Deposit Required to Bind = $10,073 (the balance of the premium can be financed on 9
monthly installments)
This indication is based on 7 units with total values of $159,662.
The quotes for the Cargo, Warehouseman's Liability, and WC will be obtained shortly.
If there are any questions please contact my office.
RUG 10 2001 12:32PM HJM.RSERJET 3200
p. 1
Urban Moving Systems, Inc,
New Jersey Headquarters
■ -Weehawken, NJ 07087
(201)558-0031 ^
New York Headquarters
446 West 50 lh Street
New York, NY 10019
(212) 338-9267-,..
npholllc Incnrgnnp
I : b6
VIA FACSIMILE: 973-661-9750 b 7 C
Dean
The informaion you requested Is below. Please call me to confirm that you received them and that the application is on it's
way.
Thank vnu, £L
Urban Moving Systems, Inc.
buhp
|| H
ill ^
H
MC 320465
NYS Dot t-33739
US Dot 691256
PC 0076006
MC 398463
USDOT 923345
4^* cdHTAmSS 4
AUG 02 2001 10:23AM
LflSER JET 3200
New Jersey Headquarters
Weehawken, NJ 070B7
(201) 5§8^0031
o \e>o
Urban Moving Systems, Inc.
New York Headquarters
446 West 50 th Street
New York, NY 10019
(212) 338-9267
DeBellls Insurance Agency, Inc.
VIA FACSIMILE: 973-661-9750
Here is a revised list of trucks that we Heed covered by our policy. I apologize for the mix-up. Please give me a call so we
can go over the details.
Revised Vehicle Schedule
1GCEG15W4Y1 142815 |$ 20,935.00
51 2001JFREIGHTLINER
200l1iNTERNATIONAL
1 HTSCAAM5X6750B7 1$
1 HSDPPN9RH559152 $
TRUCK 1 FDNK72CXPVA20054
TRUCK 1 FVABPAL91 HH68277 $
JtRUCK 1 1HISCAAM01 H393754 $
42,259.00
26.000.00
69,837.21
63.964.60
6W
8l5, 50C>
as, sea
ALL INFORMATION CONTA
EERKtNm UNCLASSIFIED
22ATE BY /JK
JliL 12 2001 3:27PM HI^RSERJET 3200
08/15/01 FR'l 08: 45 FAX 516 0^P45e r
Urban Moving Systems Inc
3 18th Street
Weehawken, NJ 07087
2000 GMC Van
1984 International Tmck
1999- International Truck
1998' International
1994 international Truck
1993 Ford' Tnrck
1993 Ford
Policy Number:
Company:
Effective Date:
Expiration Date:
Carriers Ins
08/05/2001
08/05/2002
1GCEG15W4Y1 142815 Jersey City, NJ $20,935. J $1,000.
1 HTLDUP8EHA33628 Jersey City, NJ
1 HTSCAAM5X675087 Jersey City, NJ $45,259. $1,000. $1,000.
1 HTSLAAM7WH57 4499 Jersey City, NJ $37,468.- $1,000. $ 1,000;
$ 1 , 000 ..
$ 1 , 000 :
$ 1 , 000 .
Tmck
1HSDPPN9RH559152
Jersey City, NJ
$26,000.
Tmck
■1 FDNK72CXPVA20054
Jersey City, NJ
$15,000.
Truck
1 FDNK72C2PVA1 9948
' Jersey City, NJ
$15,000.
JUL 12 2001 3:28PM
LASERJET 3200
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JUL 12 2001 3:28PM
LRSERJET 3200
p . 24
ALL IHFOPHATIOH CONTAINED
HEREIN 15 UNCLASSIFIED
DATE 07-30-2010 BY UC60322LP/PLJ/CC
Warehouse Insurance
OlaL ■ Obo, ujjlU
* (X&-
Square footage: 16,000
Construction: concrete cinder blocks
Total value of items stored: $250,000
Security: closed circuit t.v. system and audio recording
Who has access: warehouse personnel, storage manager
Sprinklers: yes
Alarm System: ADT security linked to local police station 1 block
from premises
JUL 12 2001 3:29PM
.LASERJET 3200
ALL 'INFORMATION CONTAINED
HEREIN 15 UNCLASSIFIED
481-0837 (09/99)
BY UC6Q322LP/PLJ/C
. HANOVER INSURANCE COMPANY
Worcester, Massachusetts
MOTOR TRUCK CARGO COVERAGE PART
This endorsement, effective " 8/16/00
part of Policy No. IHZ5623720
(12:01 A.M., standard time), fo rm*; ,
issued to
Urban Moving System, Inc,.
by Hanover Insurance Company.
Authorized Representative
Read the entire policy care&lly to
Parti
Applies to All Insureds
Parts II through XI Apply Only if Checked Below:
Part’ll
Partin
PartIV
Party
Part VI
Part VH
Part VUI
Part IX
Part X
Part XI
Spoilage or Freezing
Owner’s Goods Extension - Insured’s Merchandise
Owner’s Goods Extension — Extended Coverage Period
Specified Perils Including Theft
Specified Perils Excluding Theft
Theft From Locked Vehicle (Only).
Reduced Theft Limit On Target Commodities
Theft of An Entire Load (Only)
•Theft From ^Unattended” Vehicle Exclusion
Vehicle Alarm Warranty
481-0837 (09/99)
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JUL 4& 2:001 3:29PM
.LRSER JET 3200
CONTINENTAL CASUALTY COMPANY"
4 ALL IIFOPmTIOI C DHTAIHED
HE PE IN 15 UCTCLASSIFIED
DATE 07-30-2010 ET UC60322LP/PL J/CC
p. 26
WC 00 00 00 (A)
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
In return for the payment of the premium and subject to all terms of this policy, we agreed YOU as follows: * '
GENERAL SECTION
A. The Policy
This policy includes at its effective date the Infor-
mation Page and all endorsements and schedules
listed there. It is a contract of insurance between
yon (the employer named in Item 1 of the Informa-
tion Page) and us (the insurer named on the
Information Page). The only agreements relating to
■ this insurance are stated in this policy. The terms of
this policy may not be changed or waived except by
endorsement issued by us to be part of this policy.
B. \Vbo Is Insured
You are insured if you are an employer named in
Item 1 of the Information Page. If that employer is
a partnership, and if you are one of its partners, you
are insured, but only in yonr capacity as an em-
ployer of the partnership’s employees.
C. . Workers Compensation Law
Workers Compensation Law means the workers or
workmen’s compensation law and occupational dis-
ease law of each state or territory named in Item
3 A. of the Information Page. It' includes any
amendments to that law which are in effect during
the policy period. It does not include any federal
workers or workmen’s compensation law, any fed-
eral occupational disease law or the provisions of
any law that provide nonoccupational disability
benefits.
D. State
State means any state of the United" States of
America, and the District of Columbia.
E. Locations
This policy covers all of your workplaces listed in
Items 1 or 4 of the Information Page;, and it covers
all other workplaces in Item 3.A. states unless you
have other insurance or are self-insured for such
workplaces.
PART ONE-WORKERS COMPENSATION INSURANCE
A. How This Insurance Applies
3 T hi s workers compensation insurance applies to
■bodily injury by accident or bodily injury by disease.
Bodily injury includes resulting death.
1. Bodily injury by accident must occur during the
policy period.
2. Bodily injury by disease must be caused or ag-
gravated by the conditions of your employment.
The employee’s last day of last exposure to the
conditions causing or aggravating such bodily
injury by disease must occur during the policy
period.
B. We Will Pay
We will pay promptly when due the benefits re-
quired of you by the workers compensation law.
C We Will Defend
We have the right and duty to defend at our ex-
pense any claim, proceeding or suit against you for
benefits payable by this insurance. We have the
right to investigate and settle these claims, proceed-
ings or suits.
-We have no duty to defend a claim, proceeding or
suit that is* not covered by this insurance.
D. We Will Also Pay. -
We will also pay these costs, in addition to other
amounts payable under thisjnsurance, as part of
' any cl aim, proceeding of suit we defend:
1. reasonable expenses incurred at our request,
but not loss of earnings;
l
2. premiums for bonds to release attachments and
for appeal bonds in bond ( amounts up to the
amount payable under this insurance;
3. litigation costs taxed against you;
4. interest on a judgment as required by law until
we offer the amount due under this insurance;
and
5. . expenses we incur.
E. Other Insurancb
We will not pay more than our share of benefits and
costs covered by this insurance and other insurance
or self-insurance. Subject to any limits of liability
that may apply, all shares will be equal until the loss
is. paid, If any insurance or self-insurance is ex-
hausted, the shares of all remaining insurance will
he equal until the loss is paid.
F. Payments You Must Make
You are responsible for any payments in excess of
the benefits regularly provided by the workers com-
pensation law including those required because:
1. of your serious and willful misconduct;
2. you knowingly employ an employee in violation
of law;
3. youYail to .comply with a health or safety law or
regulation; or
4. you discharge, coerce or otherwise discriminate
against any employee in violation of the workers
compensation law.
If we make any payments in excess of the benefits
regularly provided by the workers compensation
law on your behalf, you will reimburse us promptly.
ot3on
Page 1 of 5
JUL 12 2001 3:31PM
HSER JET 3200
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481-0837 (09/99)
PART I GENERAL TERMS AND CONDITIONS
Throughout this policy, the words “you” arid “your” refer to
the Named Insured shown in the Declarations. The words
“we,” “us” and “our” refer to the Company providing this
insurance.
This coverage part. Part I, replaces the “Conditi^t|S*dn the
reverse of the Declarations Page (if any).
Other words and phrases that appear in quotation marks have
special meaning. Refer to Section G - DEFINITIONS.
A COVERAGE
We will pay for ‘loss’ 1 to Covered Property from any of
the Covered Causes of Loss.
carrying the property, if these causes cf “loss”
would be covered under this Coverage Form;
•g. contraband, or property in the course of illegal
transportation or trade; ■
o rib* pads, tarpaulins, handtrucks, chains, tiedowns . •
and similar equipment uscd^on or in
connection with vehicles you owner operate.
3. Covered Causes of Loss
Covered Causes of Loss means your legal liability
as a common or 'contract motor carrier, either as
■ imposed by law or assumed by contract, for Direct
Physical “Loss” to Covered Property except those
Causes of “Loss” listed in the Exclusions.
1. Covered Property, as used in this CoveiageEorm,
means property of others that you have accepted fox
transportation as a common or contract motor
carrier under your tariff and bill of lading or
shipping receipt issued by you, or as a contract
carrier under contract.
We coyer property only while:
a. contained in or on any land vehicle while in
“transit” 'and/or during “loading” or
‘‘unloading;” or
b. at premises.
But, we cover property only at premises shown in
the Declarations; coverage does not apply to*
property for which a storage charge is made.
2 . Property Not Covered
Covered Property does not include:
a. accounts, bills, blueprints, currency, deeds, ,
evidences of debt, money, notes, securities,
commercial paper or other documents of
value;
b. bullion, gold, silver, platinum or other
precious alloys or metals, jewelry, watches,
precious or semiprecious stones or similar
valuable property;
c. furs;
d. paintings, statuary and other works of art;
e. “intermodal” containers, trailers or other
carrying conveyance;
f. live animals, birds or fish except as follows: ■
We only cover your liability for theft or death
or destruction directly resulting from, or made
* necessary by fire, smoke, explosion, rioters,
strikers, civil connnotion, flood, or by
collision upset or overturn of the vehicle
4. Coverage Extensions
a. Earned Freight Charges
We cover your earned freight charges that y.ou
are unable to collect as a result of a “loss”
covered by this Coverage Form. The most we
will pay in any one occurrence is $3,000. This
limit is separate from the Limits of Insurance
shown in the Declarations.
b. Debris Removal
(1) We will pay your -expense to remove
debris of Covered Property caused by or
resulting from a Covered Cause of Loss
that occurs during the policy period. The
e^qpenses will be paid only if they are
reported to us within 180 days of the
earlier of
(a) the date of direct physical “loss;” or
* (b) the end of the policy period.
(2) The most we will pay under this coverage
is 10% of ‘the applicable Limit of
Insurance for direct physical ‘Toss” to
Covered Property, up to a maximum of
$6,000 for the sum of all such expenses
for each occurrence. The Debris
Removal Limit is separate from the Limit
of Insurance stated elsewhere in the
* policy.
c. Reloading Expense
If Covered Property is spilled as a result of an
accident to the conveying vehicle, we will pay
your expense to reload the Covered Property.
This coverage applies when there is no “loss”
to the Covered Property. The mast we will-
pay in any one occurrence is $6,000. This
limit is separate from, the Limits of Insurance
shown in the Declaration.
481-083-7 (09/99)
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JUL 12 2001 3:31PM
LRSER JET 3200
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481-0837 (09/99)
The additional coverages for Debris Removal *
and Reloading Expenses do not apply to the
cost to:
(a) extract “pollutants” from land or
•water; or
(b) femove, restore or replace polluted
land or 'water.
B. EXCLUSIONS
1. We mil not pay your liability for. a “loss’* caused
directly or indirectly by any of the following. Such
‘loss” is excluded regardless of any other cause or
event that contributes concurrently or in any
sequence to the “loss.”
a. Governmental Action
Seizure or destruction of property by order of
governmental authority.
But we will pay for acts of destruction ordered
by governmental authority and taken at the
time of a fire to prevent its spread if the fire
would be covered under this Coverage Part.
b. Nudear Hazard
(1) any weapon employing atomic fission or
fusion; or
(2) nuclear reaction of radiation, or
radioactive contamination from any. other •
cause. But we will pay for direct “loss”
caused by resulting fixe if the fire would
be covered under this Coverage Form.
c. War and Military Action
(1) war, including undeclared or civil war;
(2) warlike action by a military force,
including action in hindering or .
defending against an actual or expected
attack, by any government, sovereign or
other authority using military personnel
or other agents; or
(3) insurrection, rebellion, revolution,
usurped power or action taken by
governmental authority in hindering or
defending against any of these.
X We will not pay your liability for a “loss’* caused
by or resulting from any of the following:
a. ■ delay, loss of use, loss of market or any other
consequential loss.
b. dishonest acts by you, your employees or
authorized representatives (including operators
. under contract to you).
This exclusion applies whether or not such
persons are acting alone or in collusion with
other persons or such acts occur during the
hours of employment.
c. spoilage, deterioration, contamination,
freezing, rusting, extremes of temperature,
shrinkage, evaporation, loss -of weight, or
change in flavor, finish or texture.
But we will pay your liability for direct “loss”
caused by fire, explosion, snioke, riot or civil
commotion, vandalism or malicious mischief,
theft, collision, flood, upset or overturn of the
transporting conveyance.
3. We will not pay your liability for a “loss” caused
by or resulting from, any of the following. But if
“loss” by a Covered Cause of 'Loss results, we will,
pay for the resulting “loss.”
a. Weather conditions. But this exclusion only
applies if weather conditions contribute in any
way with a cause in event excluded in
paragraph 1 above to produce the “loss.”
t. Wear and tear, any quality in the property that
causes it to damage or destroy itself, insects,
vermin and rodents.
4. We will not pay -for any costs or penalties yon incur
for violation of any law or regulation that applies to
your delay in payments, denial or settlement of any
claim made against you by others for ‘Toss’* to
Covered Property,
C. LIMITS OF INSURANCE
1. The most we will pay for “loss” in. any one
occurrence. is the applicable Limits of Insurance
shown in the Declarations.
2. The most we will pay for 'Toss” in any one
occurrence to Race Horses, Show Animals, or High
Valued Breeding Animals is 150% of the
commodity meat price per pound on the day of the
“loss” on the Chicago Mercantile Exchange.
D. DEDUCTIBLE
We will pay only the amount of the adjusted “loss” in
any one occurrence in excess of the Deductible amount
shown in the Declarations, up to the applicable Limit of
Insurance.
E. GENERAL CONDITIONS
The following conditions apply in addition' to the
Common Policy Conditions:
1. Coverage Territory
We cover property within:
481-0837 (09/99)
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HP^RSERJET 3200
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JUL 12 2001 3:3 1 PH
481-0837 (09/99)
a. the states of the United States (excluding
Alaska);
b. Canada
but *we do nor cover any property in transit to or
frpmHawaii.
2. Valuation
Hie value of property will be the least of the
following amounts:
a. 1. the amount for which you are liable;
2. the amount of invoice, or in the absence
of an invoice, ‘the actual cash value of
that property as of the time of ‘loss;”
b. the cost of reasonably restoring that property
to its condition immediately before “loss;” or
c. the- cost of replacing that property with
substantially identical property.
In the event of “loss the value of property will be
determined as of the time of “loss.”
3. Labels
In the event of “loss” only at the identifying labels
or wrappers containing the Covered Property, we
will pay the costto replace those labels or wrappers
if the ‘loss” is caused by or results from a Covered
Cause of Loss.
4. Concealment, Misrepresentation or Fraud
This Coverage Part is void In any case of fraud,
intentional concealment or misrepresentation of a
material fact, .by you or any other Insured, at any
time, concerning:
a. this Coverage Part;
b. the Covered Property;
c. yoor interest in the Covered Property; or
d. a claim under this Coverage Part
5. Legal Action Against TJs
No one may bring a legal action against us under
this Coverage Part unless:
a. there has been full compliance with alL the
terms of this Coverage Part; and
b. the action is brought within 2 years after you
first have knowledge of the “loss.”
6. Records ^
You shall keep accurate records of your trucking
business and all" “gross receipts 33 from transportiii^^,
the property covered by this Coverage Form. You
shall retain these records for three years after the
policy ends.
- 7. Reimbursement ta Us
We may endorse this policy at your request to*
’ comply with the requirements of the Interslate'
Commerce Commission or any other governmental
authority. .
If we pay any “loss” solely because of * any such-
endorsement, you will promptly reimburse us for-
that payment and any other expense we have in
connection with that payment.
8. Adjus tment and Payment of Loss
At our option, we..may adjust the “loss” with and
pay to:
a. you, for the account of whom it -may concern;
or
b. your customer, or the owners of the Covered
Property.
If legal actions are taken to enforce a claim against
you, we reserve the right, at our option, without
expense to you, to conduct and control your
defense. This action will not increase our liability
under your policy, nor increase the Limits of
Insurance specified.
9. No Benefit to Bailee
No person or organization, other than you, having
custody of Covered Property, will benefit iiom this
insurance.
It). Policy Period
We' cover “loss” commencing during the policy
period shown, in the Declarations.
11. Excess Insurance
You agree that no excess insurance over and above
the Limits of Insurance of this policy shall be
provided by any other policy.
F. LOSS CONDITIONS '
1. Abandonment
There can be no abandonment of any property to
us.
2. Appraisal '
If we and you disagree on .the value of the property
or the amount of ‘loss,” either may make written
demand for an appraisal of the “loss.” ’ In this
event each party will select a competent and
impartial appraiser. The two appraisers will select
an umpire. If they cannot agree, either may request
that selection be made by a judge of a court having
481-0837 (09/99)
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JUL 12 2001 3:32PM
^ LASERJET 3200
481-0837 (09/99)
jurisdiction. The appraisers will state separately
the value of the property and amount of “Loss.” If
they fail to agree, they will submit their difference
to the umpire. A decision agreed to by any two
will be binding. Each part will:
a. pay its chosen" appraiser; and
b. bear the. other expenses of the appraisal and
umpire equally.
If there is an appraisal, we will still retain our right
to deny the claim.
3. ‘ Duties in the Event of Loss
You must see that the following are done in the
event of “loss” to Covered Property:
a. Notify the police if a law may have been
broken.
V Give us prompt notice of the ‘loss” Include a
description of the property involved.
c. As soon as possible, give us a description of
how, when and where the “loss” occurred.
& Take all reasonable steps to protect the
Covered Property from further damage. If
feasible, set die damaged property aside and in
die best possible order for examination. Also
keep a record of your expenses, for
consideration in the settlement of the claim.
e. Make no statement that will assume any
obligation Dr admit any liability, for any “loss”
for which wc may be liable, without our
consent.
f. Permit us to inspect the property and records
proving ‘loss.”
g. If requested, permit us to question you under
oath, at such times as may be reasonably
required, about any matter relating to this
insurance or your claim, including your books
and records. In such event, your answers must
be signed.
h. Send us a signed, sworn statement of “loss”
containing the information we request to settie
the claim. You must do this within 60 days
after our request. We wilL supply you with the
necessary forms.
4. Insurance Under Two or More Coverages
If two or more of this policy 1 s coverages apply to
the same “loss," we will not pay more than the
actual amount of the “loss ”
5. Loss 'Payment
* We will pay or make good any ‘Toss” covered
. under this Coverage Part within 30 days after.
a. we reach agreement with you;
b. the entry of final judgment; or
c. the filing of an appraisal award.
We will not be liable for any part of a “loss” that
has been paid or made good by others.
6. Other Insurance
If you have other insurance covering the same
.“loss” as the insurance under this Coverage Part,
we will pay only the excess over what you should
have received from the other insurance. We will
pay the excess whether you can collect on the other
insurance or not
7. Pair, Sets or Parts
• a. Pair or Set. In case of “loss" to any part of a
pair or set we may:
1. repair or replace any part to restore the
pair or set to its value before the “loss,”
or
2. pay the difference between the value of
the pair or set before and after the “lbSs.”
b. Parts. In case of “loss” to any part of Covered
Properly consisting of several parts when
complete, we will only pay for die value of the
lost or damaged part,
8. Privilege to Adjust with Owner
In the event of “loss” involving property of others
in your care, custody or control, we have the right
to: ■
. • a. Settle the “Loss” with the owners of the
property. A receipt for payment from the
owners of that property will satisfy any claim
of yours.
1. Promptly send us any legal papers or notices
received concerning the “loss.”
j. Cooperate with us in the investigation of
settlement of the claim.
k You must promptly make claim in writing
against any other .party who may be liable for
the “loss”*
b. Provide a defense far legal proceedings
brought against you. If provided, the expense
of this defense will be at our cost and will not
reduce the applicable Limit of Insurance under
this insurance. ,
481-0837 (09/99)
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H
RSERJET 3200
p. 5
PART FOUR- YOUR DUTIES IF INJURY OCCURS
Tell us at once if injury occurs that may*be covered by
this policy. Your other duties are listed here.
1. Provide for immediate medical and other services
required by the workers compensation law.
2. Give us or our agent the names and addresses of the
injured persons and of witnesses, and other infor-
mation we may need. ^
3. Promptly give us all notices, demands and legal
papers related to the injury, claim, proceeding or
suit*
PART FIVE
A. Our Manuals
All premium for this policy will be determined by
our manuals of rules, rates, rating plans and classi-
fications. We may change our manuals and apply
the changes to this policy if authorized by law or a
governmental agency regulating this insurance.
B. Classifications
Item 4 of the Information Page shows the rate and
premium basis for certain business or work classi-
fications. These classifications were assigned based
on an estimate of the exposures you would have
during the policy period. If your actual exposures
are not properly described by those classifications,
we will assign proper classifications, rates and pre-
mium basis by endorsement to this policy.
C. Remuneration
Premium for each .work classification is determined-
by multiplying a rate times a premium basis. Re-
muneration is the most common premium basis.
This premium basis includes payroll and all other
remuneration paid or payable during the policy
period for the services of:
1. All your officers and employees engaged in
work covered by this policy; and
2. All other persons engaged in work that could
make us liable under Part One (Workers Com-
pensation Insurance) of this policy. If yon do
not have payroll records for these persons, the
contract price for their services and materials
may be used as the premium basis. This para-
graph 2 will not apply if you give us proof that
theemployers *of these persons lawfully secured
their workers compensation obligations.
D. Premium Payments
You will pay all premium when due. You will pay
the premium even* if part or all of a workers com-
pensation law is not valid.
E. Final Premium
The premium shown on the Information Page,
schedules, and' endorsements is an estimate. The
final premium will be detennined after this policy
4. Cooperate with us and assist us, as we may request,
in the investigation, settlement or defense of any
claim, proceeding or suit.
5. Do nothing after an injury occurs that would inter-
fere with our right to recover from others.
6. Do not voluntarily payments, assume^miga-
tions or meur expenses, except at your own cost.
-PREMIUM
ends by using the actual, not the estimated, pre-
mium basis and the proper classifications and rates
that lawfully apply to the business and work covered .
by this policy. If the final premium is more than the
premium you paid to us, you must pay us the- bal-
ance. If it is less, we will refund the balance to you.
The final premium will not be less tHSn the highest
minimum premium for the classifications covered
by this policy.
If this policy is canceled, final premium will be
determined in the following way unless our manuals
provide otherwise:
1. If we cancel, final premium will be calculated
pro rata based on the time this policy was in
force. Final premium will not be less than the
pro rata share of the minimum premium.
2. If you cancel^ final premium will be more than
prq rata; it will be based on the time this policy
was in force, and increased by our short-rate
cancellation table and procedure. Final pre-
mium will not be less than the minimum pre- ■
mium.
F. Records
You will keep records of information needed to
compute premium. You will provide us with copies
of those records when we ask for them.
G, Audit
You will let us examine and audit all your records
that relate to this policy. These records include
ledgers, journals, registers, vouchers, contracts, tax
reports, payroll and disbursement records, and
programs for storing and retrieving data. We may
conduct the audits during regular business hours
during the policy period and within three years
after the policy period ends. Information developed
by audit will be used to determine final premium.
Insurance rate service organizations have the same
rights we have under this provision.
PART SIX - CONDITIONS *
A. Inspection
We have the rights but are not obliged to inspect
your workplaces at any time. Ckir inspections are
not safety inspections. They relate only to the insur-
ability of the workplaces and the premiums to be
charged. We may give you reports on the conditions
we find. We may also recommend changes. ' While
they may help reduce losses, we do not undertake to
erform the duty of any person to provide for the
ealth or safety of your employees or the public.
We do not warrant tiiat your workplaces are safe or
healthful or that they comply with laws, regulations,
codes or standards, Insurance rate service organi-
zations have the same rights we have under this
provision.
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Page 4 of 5
JUL 12 2001 3:33PM
LASERJET 3200
. Recoveries
Any recovery or salvage* on a "loss” will accrue
entirely to our benefit until the sum paid by us has
'been made up.
10. Reinstatement of Limit After Loss
The Limit of Insurance will not be reduced by the
payment of any claim, except for total ‘loss” of a
scheduled item, in which event we will refund the
unearned premium on that item. *
!? a JJ sfer of Rights of Recovery Against Others
To Us
If any person ^organization to or for whom we
make payment under this- insurance has rights to
recover damages from another, those rights are .
transferred to us. That person or organization must
do everything necessary to secure our rights and
must do nothing after "loss" to impair them.
You may accept bills of lading or shipping receipts
issued by other carriers that limit their liability to
less than the actual value of the property.
G. Definitions
Loss means accidental loss or damage.
<4 Gross receipts” means the total amount of receipts to
which you are entitled for the packing, loading
unloading and transporting of Covered Property!
regardless of whether you or another carrier originated
the transportation.
Pollutants means any solid, liquid, gaseous or
thermal initant or contaminant including smoke, vapor,
soot, fumes, acids, alkalis, chemicals and waste. Waste'
includes material to be recycled, reconditioned or
reclaimed.
Transit begins with the actual movement of the goods
from the point of shipment bound for a specific
destination. It remains in transit during the ordinary,
reasonable and necessary stops, interruptions, delays or
transfers incidental to the route and method of shipment
including rest periods taken by the drivers). Transit
ends upon acceptance of the goods by or on behalf of the
consignee at destination, but shall not extend beyond
168 hours following arrival at destination.
Tutcrmada] containers are containers used in
combination with another mode of transportation such
as trailer on flatcar.
Loading” means the lifting or moving of Covered *
Property from the ground, or a loading platform
immediately adjacent to the transporting conveyance,
onto the transporting conveyance.
"Unloading” means the lowering or moving of Covered
Property from the transporting conveyance to the
ground, or a loading platform immediately adjacent to
the transporting conveyance.
H. Cancellation
This policy may be cancelled by the Insured by
surrender thereof to the Company or any .of its
Authorized agents or by mailing to the Company written
notice stating when thereafter such cancellation shallbe
effective. . Ihis policy may be cancelled by the
• Company by mailing to the Insured at the address shown
m this policy or last known address written notice
stating when, not less than five (5) days thereafter such
cancellation shall be effective. The mailing of notice as
aforesaid shall be sufficient proof of notice. The time of
surrender or the effective date of the cancellation- stated
m the notice shall become the end of the policy period
Delivery of such written notice either by the Insured or
by the Company shall be equivalent to mailing.
If the Insured cancels, earned premiums shall be
computed in accordance with the customary short rate .
table and procedure. If (he Company cancels, earned ‘
premiums shall be computed pro 'rata. Premium
adjustment may be made at the time cancellation is
effected and, if not then made, shall be made as soon as
practicable after cancellation becomes ‘effective. The
Company s check ox the check of its representative
maded or delivered as aforesaid shall be a sufficient
tender of any refund of premium due to the Insured,
L Changes
Notice to any agent or knowledge possessed by any
agent or by any other person shall not effect a waiver or
a change in any part of this policy or estop the Company
from asserting any right under the terms of this policy, ’
nor shall the terms of this policy be waived or changed!
except by endorsement issued to form a part of this •
policy.
J. Conformity to Statute
Terms of this policy which are in conflict with the
statutes of the State wherein this policy is issued are
hereby amended to conform to such statutes.
481-0837 (09/99)
Page 6 of 8
JUL 12 2001 3:34PM
P-7
• 481-0837 (09/99)
PART II SPOILAGE OR FREEZING PART IV OWNER’S GOODS EXTENSION -
We will pay for ‘logs” to -Covered Property caused by
spoilage or freezing due to mechanical or electrical
breakdown of refrigeration or heating equipment, while on
vehicles you own or ^operate, subject to the following
additional conditions: *
We will not pay for spoilage or fre ezing due to:
1. lack of fuel required to operate refrigeration or
healing equipment;
2. disconnecting or unplugging refngeraticn or
heating equipment, or termination of power by
turning off switches or similar devices;
3. ’ failure to perform proper “maintenance” of the
cooling . or heating equipment according to
manufacturer's recommended schedule.
“Maintenance” means:
1. to inspect cooling and heating equipment by you
or your qualified representative at least once
. every 30 days;
2. repair or replace equipment as necessary;
3. record maintenance activities. These records will
be available to us upon request
PART m OWNER’S GOODS EXTENSION -
INSURED’S MERCHANDISE
We provide coverage for loss or damage to your lawful
goods and merchandise. The property must be in your
custody and actualiy in “transit,” in or on vehicles operated
by you.
We do not cover your property while: . -
1 in or on your premises;
2. in any garage or other building where your
vehicle(s) are usually kept
Such merchandise shall be valued at amount of invoice, or
in the absence of invoice, at market value on date and at
place of shipment
Our liability shall not exceed the limits specified in the
pCficy declarations for
1. the property of others for which you are legally
liable;
2. the value of your own goods; or
3. both combined.
EXTENDED COVERAGE PERIOD
Coverage on your property attached upon “loading” and
ceases when “unloaded.”
u
ie Loading” means the lifting or moving of the Covered
Property from the ground or loading platform immediately
adjacent to the transporting vehicle onto the transporting
vehicle.
‘"Unloading” means the lowering or moving of the Covered
Property from the transporting vehicLe to a loading platform
or the ground immediately adjacent to the transporting
vehicle. It is “unloaded” and coverage ceases' when
property has been lowered to or placed upon the ground or
loading platform.
We will not cover property while it is being installed,
erected or dismantled.
PART V SPECIFIED PERILS INCLUDING
THEFT
Clause A3. COVERED CAUSES OF LOSS is replaced
by the following:
Covered Causes of Loss means your legal liability as a
common or contract motor carrier, either as imposed by law
or assumed by contract for “loss” to Covered Property
caused by or resulting from:
1. fire, explosion, windstorm;
2. collision of a cargo carrying vehicle with any
other vehicle or object, excluding contact with
any portion of the roadbed, or curbing, and
excluding the coming* together of railroad cars
during shilling or coupling,
3. overturning of .the cargo carrying vehicle;
4 . collapse of bridges and culverts;
5. stranding, sinking, burning or collision of any
regular feny or railroad carfioat (including
general average and salvage charges for which
you may be liable);
6 . “flood” means “loss” to property, but only while
such property is in transit, caused by any of the
following:
a. the overflow of any body of water;
b. the release of water impounded by a dam; or
c. any rapid accumulation or runoff of surface
water.
7. theft of an entire shipping package.
481-0837 (09/99)
Page 7 of 8
JUL 12 2001 3:34PM
LASERJET 3200
PjLRT VI SPECIFIED PERILS EXCLUDING
THEFT
* “« «
Sl!* d , Ca T 0f ®«9“ y™ legal liability as a-
n or contract motor carrier, either as imposed by law
or assumed by contract for ‘loss” to Covered Property
caused by or resulting ftom: ‘
1* fire, explosion, windstorm;
2. collision of a cargo carrying vehicle with any
other vehicle or object, excluding contact with
any portion of the roadbed, or curbing, and
excluding the coming together of railroad cars
during shifting or coupling
3- overturning ot the cargo carrying vehicle;
4. collapse of bridges and culverts;
5. stranding, sinking, burning or collision of any
regular- ferry or railroad carfloat (including
general average and salvage charges for -which,
you may be liable);
. <!• "flood” means ‘loss” to property, but only while
such property is in transit, caused by any of the ■
following: .
8- the overflow of any body of water;
b. the release of water impounded by a dam; or
e. any rapid accumulation or runoff of surface
water. -
PART IX
THEFT OF AN ENTIRE LOAD
(ONLY)
PAKryn
THEFT FROM LOCKED
VEHICLE (ONLY)
J* Pfy & caused by theft of Covered
Propaty from “unattended” vehicles which you own or
operate, unless:
1. at the time of "loss” the doors, windows and
coriLpaxtments of the vehicle(s) were closed and
locxfid;
2. there are visible signs on the exterior of the
vehicle that the theft wasaresult of forced entry.
PART VIH REDUCED THEFT LIMIT ON
TARGET COMMODITIES
The most we will pay for “loss” caused by theft of
■ g kqhohcbeverap r * (other than beer and vrine), dr^ri
^ a pnaceuttcals, electroni cs e quipment ■
jOfracco products, and prm i oug metals and alli^w i.)™* rf
£>5 omf* 16 Li “S ° f hsurailce > u P to a maximum of
2)25,000 m any one “loss ”
Theft coverage provided by your policy for Covered
Property tn or on vehicles is limited to “loss" caused bv
theft of an. entire carload, truckload, trailerload or
container, excluding theft by your employes or authorized’
representative (whether or not suchpersons are acting alone
PARTX THEFT FROM “UNATTENDED”
VEHICLE EXCLUSION
We will not pay for "loss” by theft of Covered Property
from an ‘unattended” velhcle which you own or operate
“Unaftended”means (a vehicle) without a person on or in
^vehicle, whose duty is tcsafeguard the vehicle and its
PART XI VEHICLE ALARM WARRANTY
We TOll nay for any “loss” caused by theft of Covered
rraperty from vehicles owned or operated by you, unless:
1. flie vehicles) are equipped with a Theft Alarm
' System;
2. this alarm equipment is maintained in good
workmg order at all times and inspected and
approved at least 'once each. 60 days by the
manufacturer, or any of its authorized
representatives, and proper inspection certificates
issued;
3. flie alarm equipment protecting the cargo
compartment of each vehicle is in the “ON”
position while merchandise is in the
compartment, except while being loaded or
unloaded;
4. during loading and unloading, at least one
employee will attend the cargo compartment to
guard the contents.
481-0837 (09/99)
Page 8 of 8
I
JUL 12 2001 3:35PM
LASERJET 3200
B. Long Term Policy
If the policy period is longer than one year and six-
teen days, all provisions of this policy will apply as
though a new policy were issued on each annual
anniversary that this policy is in force,
C. Transfer of Your Rights and Duties
Your rights or duties under this policy may not be
■transferred without our written consent.
If you die and we receive notice within thirty days
after your death, we will cover your legal repre-
sentative as insured. ^
D. Cancelation
^ ma y cancel this policy. You must mail or
deliver advance written notice to us stating
when the cancelation is to take effect,
In witness whereof, the company has caused this policy
Connecticut, and countersigned on the information, page 1
2. We may cancel this policy. We must mail or
deliver to you not less than ten days advance
written notice stating when the cancelation is :o
take effect. Mailing that notice to you at your
mailing address shown in Item 1 of the Infor-
mation Page will be sufficient to prove notice.
3. The policy period will end on the day and horn-
stated in the cancelation, notice.
4. Any of these provisions that conflict with a law
that controls the cancelation of the insurance in
this policy is changed by this statement to com-
ply with the law.
E* Sole Representative
The insured first named in Item 1 of the •
Information Page will act on behalf of all insureds
to change this policy, receive return premium, and
give or receive notice of cancelation.
be signed by its President and Seeretaiy at Hartford,
a duly authorized agent of the company.
■b6
b7C
n f|s WC 00 00 00 (A)
n;
ALL INFORMATION COHTAIHED
HERE IN 15 UNCLASSIFIED
DATE 07-30-2010. BY- UC60322LF/FL J/CC
i
i
F
CP-3349 Edition 2-92 Printed in U.SA (12-94) .
."Includes copyright material of the National Council on
Compensation Insurance, used with its permission.
©1991 National Council on Compensation Insurance.”
Page-5 of 5
Q13013
JUL
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!
I
i
O130U
1.2; 2001 3:35PM
LRSER JET 3200
p. 10
CNA
ForAtl the Commitments You itelee*
ALL INFORMATION CONTAINED
HERE II IS UNCLASSIFIED
DATE 07-^0-2010 BY UC60322LP/PL J/CC
WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
» M TYPE AR INFORMATION PAGE WC 00 00*04 ( A)
NO TAX IDENTIFICATION NO.: 223511891000
POLICY NUMBER: (6S59UB-674X651 -5-00)
NEW-00
INSURER: CONTINENTAL CASUALTY COMPANY
1. INSURED:
URBAN MOVING SYSTEMS INC
3 18TH STREET
WEEHAWKIN NJ 07087
NCCI CO CODE: 1 0243
PRODUCER:
A E GOETTELMANN S CO INC
1208 NORTHERN BLVD .
PO BOX 1208
MANHASSET NY 11030-4308
Insured Is a corporation
Other work places and Identification numbers.are shown in the schedule® attached.
2. The policy period IS from OSMS-oo to os-ts-ot 12:01 A.M.atthe Insured’s milling address,
sahon K ^rftheS^™adS RANt ^ E: Pan0ri80,,he P° lic y applies to the Workers Compsn-
NJ
B.
C.
•• SSSSSm- . '
Bodily injury by Disease: •$ ,00000 Ea£h&$oyee
o™er STATES INSURANCE: Pad Three of the policy applies to the states, If any, listed here:
COVERAGE ' EXCLUDED .
D. This policy includes these endorsements and schedule's:
SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
J^nc re ir m f ? r P° ,ic y win b .® determined by our Manuals of Rutes, Classifications Rates and Ratlnn
Pteha. All required Information Is subject to yerlfloatlon and change by kuditlo S mSeStluy 3
DATE OF ISSUE: 1 0-20-00 HB'
OFFICE: CNA ' , 04J
PRODUCER: A E GOETTELMANN &-C0 INC
725LW.
ST ASSIGN: Nd
|
i
JUL 12 2001 3:36PM
p. 1 1
.LASERJET 3200
OVA
Far AG f ha Ce/nmlmonU You UiMa*
WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
* ' <r *
EXTENSION OP INFO PAGE -SCHEDULE- WC 00 00 01 ( A)
• POLICY NUMBER: (6S59UB-G74X651 -5-00 )
INSURER: CONTINENTAL CASUALTY COMPANY
INSURED'S. NAME: URBAN MOVING SYSTEMS INC
EXP. MOD. EFFECTIVE DATE: 09-18-00
CLASSIFICATION C0DE
LOCATION 001 01
FEIN ‘223511891 ENTITY CD 001
MDH^ X ^wff!I IFICATI0N N0 - : 223511891000
URBAN MOVING SYSTEMS INC
3 . 1 8TH STREET
WEEHAWKIN, NJ 07087
FURNITURE MOVING & STORAGE
.555 DRIVERE • . . 8293
“ SB CLERICAL OFFICE EMPLOYEES NOC 8810
1 0243-NJ
RATE BUREAU ID: 3172GG
PREMIUM BASIS
TOtSFSSSl OF aS TED
REMUNERATION REMUNERATION ‘ PREMIUM
236620
IF ANY
21556
TOTAL PREMIUM SUBJECT TO EXPERIENCE MODIFICATION
CONTINGENT EW MOD: 1 .356 MODIFIED PREMIUM
• e no»/ T 2, T ^ L . ESTIMATED ANNUAL STANDARD PREMIUM
6.00/4 PLAN PREMIUM ADJUSTMENT PROGRAM (0942)
. 2.90% PREMIUM DISCOUNT (0064)
8.80% 0935 NJ SECOND E INJURY FUND^URChS
■TOTAL ESTIMATED PREMIUM
DEPOSIT AMOUNT DUE
21 556
29230
29230
1754
848
160
2572
32868
32868
DATE OF ISSUE: 1 0-20-00 HB
ST ASSIGN: NJ
SCHEDULE NO: 01 OF LAST
JUL 12 2001 3 s 36PM
3
p. 12
1
LASERJET 3200
CNA
rbrAU IfipCo/nmJOnartj rtrj Malta*
WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
ENDORSEMENT WC 00 04 12 (00)
POLICY NUMBER: (6S59UB-674X651 -5-00 )
j CONTINGENT EXPERIENCE
RATING MODIFICATION FACTOR ENDORSEMENT
The premium for this policy will be adjusted by an experience rating modification factor. The factor shown in the
schedule Is a Contingent Experience Rating Modification factor based on the appropriate experience data available
and supersedes any prior experience modification factor. We will issue an endorsement to show a revised factor
If appropriate additional experience data becomes available. The Contingent factor will apply unless a revised
factor is subsequently issued.
. SCHEDULE
STATE MODIFICATION
Nd 1 .3560
DATE OF ISSUE: T 0-20-00 ST ASSIGN: NJ
013016
JUL 12 2001 3 : 36PM
LASERJET 3200
OVA
FarAU ffte Cammitmtoi* Thu J IfjJhj*
WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
ENDORSEMENT WC 29 04 07 (00)
POLICY NUMBER: ( 6S59UB-674X651 -5-00)
NEW JERSEY PREMIUM DISCOUNT ENDORSEMENT
(SCHEDULE X)
w a N ,T Je T y P? mlu ^ for this P° lic y and the Ponies, if any, listed in Item 2 of the Schedule may be elidible
for a discount. This endorsement shows the discount rates in item 1 of the Schedule The final ralmlarirtn nf
SST dto ’“ »" *"»*•'' *w » — - your New
i n pe“K““ n at™ rar “ PS0 " V9 ra “" 3 aPplleS ' a " ‘ he preml ” ™* * subject «°
So much of the New Jersey Standard Premium as is subject to retrospective rating shall not be subiect to
discount. The remainder is subject to discount and the discount is calculated as follows:
(a) Determine the discount as though none of the Standard premium is subject to retrospective rating.
(b) Determine thediscouot as though only the premium subject to retrospective rating is discounted.
(c) The difference between (a) and (b) is the applicable premium discount.
SCHEDULE
T PREMIUM DISCOUNT. The first $5,000 of the Standard Premium shall be charged In full without discount
?o%Tnd the ? t0 h* discou " t . of 3 - 5% - the nsxt $400,000 shall be subject to a discount of
o.o%, and the remainder shall be subject to a discount of 7.0%.
2. OTHER POLICIES:
• DATE OF ISSUE: 1 0-20-00 ■ ST ASSIGN:
JUL 12 2001 3 : 36PM
LRSERJET 3200
WORKSHEET TOR WORKERS' COMPENSATION TELEPHOMF pppodtim^
' CalUtfe rib R h EM «W H EN COMPLETING THE INFORMATION BELOW: ONE REPORTING
DONOTDeSy K m h ^^We e ^!lprodu« k in^ foms^" 831 ' 0 ' 1 " ljUneS - W ® VM b ® aslrin9 V ° U ,he foilowing < > U5stions . so please
DO NOT DELAY IM CALLING IF YOU nn NOT HAVE ANSWERS 7o ALL OF THE QUFSTirwu.<?
m ,
( ) l • -LAST) CALLER'S TITLE |*BE NERT STATE
EMPLOYER'S NAME L ) EMPLOYER'S ADDRESS ,S I HEET dTV 1
_ ZP } EMPLOYER'S MAILING ADDRESS (STREET, CITY. STATE &.zl^
PARENT COMPANY/INSURED S NAME n'^ A Tin>. - i — □ SAME
LOCATION CODE NATURE OF BUSINESS POLICY cn&in
POLICY FORM POUCY NUMBER
’ ‘ -* (6S59UB-674X65 1-5-00)
tMPLCYEE’s name (first, mi. LAST) - EMPLOY EE INFORMATION
GENDER SOCIAL SECUROY NUMBER -
^-"■wicea wvilLIHU AOOPSSS (SIRtikT, CfTY, STAJE& 2 IP) ^
MnmiAL STATUS EMPLOYMENT STATUS CODE |Nd OP DEFENDERS I CUES l£ YE f MiS-WI H IWAorPr B ,nr>
— !□ FULL-TIME DpART-TiJ WAGE PERIOD HOMEPHOME NUMBER '
o ateofimjury ACCIDENT INFORMA T ION ~r~
UK,bU fOEMPLOV£i - " 'HEE.RLOYER' S PR EM ,SE S -
LOCATION OF AOciDENT ADDRESS f^EET^CITY. Stat pji ^ ^ !□ YES CD NO
" COUNTY
IP YES PnO
• UAIfeUSAUIUlY BEGAN
SAW RYTOOTiNUro? ■ TOA ^P^IIon^ORED EvlS? WAS ACCI0ENT FAIALY IF YES DATEOF DEATH
full DESCRIH I ION OF ACCIDENT
I ■ w w^YirniNi-oruw;
UYES Dno Dyes Dno
JDyes Dno
CAUSE 0= ACCIDENT (EG., SUP/FALL, LIFTING, CHEMICAL)
CONTRIBUTING FACTORS
IF OTHER PARTIES WERE INVOLVED
NAME (FIRST, Ml, LAST)
^ MOTOR VEHICLE ACCIDENT, DRIVER'S LICENSE NUMBER STATE WHERE ISSUED -
EQUIPMENT, MATERIAL OR SUBSTANCE I WOLVH3 ^
PHONE NUMBER
WERE SAFEGUARDS PROVIDED? DESCRIPTION OF SAFEGUARDS
□yes Dno
WITNESS INFORMATION ^
NAME (FIRST, MI, LAST)
WERE SAFEGUARDS USED?
□ YES □ NO
PHONE NUMBER
H la Ma^ ! ■«— ,
CUMULATIVE INJURY? IF YES. LENGTH OF EXPOSURE NATURE OF DUTIES
< gS Dyes Dno
]g - :
=== □ FIRST AID -
□ yes Df
WHAT TYPE OF FIRST AID WAS ADMINISTERED?
HOSPITAL/
U CLINIC-
□ PHYSICIAN -
1 WUNTCG98
NAME AND ADDRESS (STREET, C ITY, STATE & 2iP) 1 TREATMENT
~NAM £ AND ADDRESS (STREET, CITY, STATE & ZIP) "P HONE NUMBER *
( ) -
LENGTH OF TIME DOING ACTIVITY
j 1ST DAY OF TREATMENT
[ LENGTH OF STAY 1ST DAY OF TREATMENT
I SPECIALTY PlST DAY OF TREATMENT
CONTINUED ON REVERSE SIDF !
1:2 2001
LASERJET 3200
WORKERS’ COMPENSATION - FIRST REPORT OF INJURY - STATE SPECIFIC QUESTIONS
Alabama ” ~ ' *
Employee's county
Employer's 10 (U.C. Account) Number
•Specific product (e.g., tires)
Alaska " ’ “
Side of body affected (left or right) * «
Employer's Alaska address (if different from mailing address)
Date and time employee left work
Scheduled days off
Time workday began
Was accident caused by failure of a machine or product?
f injury was caused by a mechanical part, specify part
If the accident was caused by anyone besides employee, give name
and address
If fatal, name and address of dependents
If you doubt validity of claim, state reason
Alaska Unemployment Insurance Account Number (U.L Acct No.)
Arizona ■ “ “
Last date of work after injury
Number of days per week company usually works
Department number
If validity of claim is doubted, state reason
If another person not employed by company caused accident give
name and address .
Was worker in your employ when Injured?
Hours per day employee worked the day of injury
Will work loss exceed 7 days?
Was injured paid for the day of Injury? (If yes, specify amount)
Was employee* hired for permanent employment?
Number of months employment available during the year
Is employee furnished lodging or board? (If yes, specify value) ■
Does employee claim dependents?
Actual gross earnings of employee for the 30 calendar days
preceding injury
Is employee paid other than fixed weekly or monthly salary?
£>oes employee earn extra pay for overtime? (If yes, basis of
paymenl/hourly amount)
Number of hours overtime considered normal per week
Has injured been employed for more than 12 months?
^thr 5 V '^ eS during 12 months preceding injury (from-
Gross wages of employee from date of hire through date of accident
Has employee received a wage increase within 12 months prior to
increa ^ Speclf ^ clate ' wa 9 e/ P er before and wage/per after
Gross earnings from date of increase through day prior to injury
Was employee in overtime when injured?
California
State Unemployment Insurance Account Number
Type of employer (pri^te/state/crty/county/school district/other
government)
Was employee unable to work For at least one full day after the date ‘
of injury?
Date employee was provided claim form
Colorado
How long has employee worked Tor this employer?
Employee’s length of experience at this assignment
Years of education completed (6 to 20)
Number of employees
If employes has not returned to work, estimate date of return
Did injury occur because of intoxication, failure to use safety
devices, failure to obey rules?
Will benefits continue during disability? m ‘ -
If employee’s health insurance benefits discontinue, what will the
weekly cost be for continuing such benefits?
If fatal, give name, relationship and address of closest dependent of
deceased .
Is employee receiving overtime, commissions or piecework?
Connecticut ~~ ‘ “ ' “
Reason fer-report (lost time/medical-health carefoccupational
disease/correct prior report)
I Time employee's workday began
Extent of accidenUhealth and life coverage for employee
For Occupational DiseaseLC^V % ,
Date of last exposure ^
Date of diagnosis as occupationally related
Employer's Registration Number (CRN)
Was employee treated in an emergency room?
Delaware
Employer's UC Reporting Number
Employee’s county
if employee has returned to .work, at same wage?
District of Columbia
If employee has returned to work, at what time?
Was injured hired in DC?
Was injured given Form #7 DCWC? -*
Piece or time worker
Florida ” "
Time injury was reported
Rate of pay /per
Was physiclan/hospital authorized by employer?
Does the employer agree with the description of accident?
Did the employee knowingly refuse to use safety equipment provided
by you, the employer?
■ Did the employee request medical care? (If yes, did the employer
provide medical care?)
Georgia " “ ~ —
Specific products (e.g., tires)
Hawaii [ '
Was employee furnished meals or lodging?
Monthly salary
Department of Labor Number
Medical deductible
IF gratuities (tips,' etc.) were received in the course of employment
estimate weekly value
Length oF time employed by you at this occupation
If mechanical apparatus or vehicle caused injury, what part of it
caused injury?
Type of treatment (inpatient/outpatient)
If fatal, name and address of nearestjelative *
What was employee doing when the accident occurred?
Illinois ”* — — — —
Illinois Unemployment Compensation Number
SIC Number
Total number of employees at the location where illness or Injury
occurred
Was employee given Industrial Commission Handbook?
Did incident result in occupational injury or occupational disease?
What unsafe act by a person caused or contributed lo the injury or
illness? - 3
Indiana ; “ 7 ~
Number of lost workdays to date
Iowa
Number of employees
Was injury caused by failure to use safely equipment or observe
regulations?
If employee has not returned to work, probable length of disability
Is the injury expected to produce permanent disability?
013019 WUNTDG98
Page 1 of 4
* j - * Was injured hired in New Hampshire?
j Piece or time worker
i j Tima disability began
Has injured filed a Farm 8a WCA?
Part of machine on which accident occurred?
Kind of power (e.g., hand, foot, electrical, steam, etc.)
Was accident caused by injured's failure to use or observe safety
equipment or regulation?
Probable length of disability
If employee has returned to work, at what time?
Federal I.D. Number,
Has employee returned to full or light duty?
Initial treatment (none, employer, emergency, hospitalized,
outpatient, clinic or office visit)
if employee Is a teased or temporary worker, client's business name
Is there a managed care program? (If yes, name of provider)
Is there a written safety program in force?
Is there an active safety committee?
Number of employees, full time and part time
SIC Code
New Jersey
Number of employees
Was employee unable to work on 'any day after the inyjry?
SIC Number
Employer's Registration Number
Ohio
Time accident reported to employer
Has employee ever filed a previous application for this injury?
Has employee filed any other claims with the Bureau or Industrial
Commission? (If yes, specify claim number and body parts)
Employee’s county
Employer's Risk Number
if under your employ for less than 12 months prior to injury, list
former employers, dates if employment, wages and number of
weeks
Oklahoma
SIC Number
Oregon
Education (number of years completed, or GED)
Side of body affected (left or right)
Department regularly employed
T ype of employer (individualfcorporation/partnership/olher)
Is worker an owner or corporate officer?
Did injury occur during the course of employment?
Was accident caused by failure of machinery or product?.
Did someone (not worker) cause accident?
Time worker left work
Explain if number of hours per shift or week varies
Scheduled days off
New Mexico
Federal ID Number
NM Unemployment Insurance Number
Does your business have a safety program? (If yes, specify admini-
stered period - weekly/monthly/ annuallyfother - if other, specify)
Highest educational level attained
Total lost work days
If occupational iflness, date diagnosed and description of diagnosis
Was employee under the influence of drugs/alcohol? (Yes/no/
unknown)
Pennsylvania ■
Employer's Unemployment Compensation Reporting Number
If employee has returned to work, at what .wage?
Employee's county
If employee is under age 18, Certificate Number and occupation for
which issued
Did injury occur because of mechanical defect or unsafe act?
Was employee amputated?
South Dakota
Federal ID Number
New York .
Code Number
NYS U.l. Employer Registration Number
Total earnings paid during 52 weeks prior lo date of accident
(include bonuses, overtime, value of lodging, elc.)
Did employer provide medical care? (If yes, when?)
Has the injury/illness been previously reported on Form C-2.1?
Indicate days of week that employee regularly works
If fatal, name, address and relationship of nearest relative
North Carolina
Employer Code Number •
Time disability began
Kind of power (hand, foot, electrical, steam, etc.)
Part of machine on which Injury occurred
Was accident caused by inbred’s failure to use or observe safety
' equipment or regulation?
Probable length of disability
If employee has returned to work, at what time7
Unemployment Number
SIC Code Number
Number of employees
Is the employee an officer or partner?
Time workday began
Exemption information (employee/spouse/over 65/blind/other
dependents)
Does employee receive pay in kind? (If yes, explain)
Type of treatment (outpatient, emergency room or in house)
Injury Cades:
Body part injured (2 digits)
Cause of inpjry (2digits)
Nature of injury (2digits)
Tennessee
Federal ID Number
If paid on other than a time basis, such as piece work or
commissions, indicate method and actual average weekly earnings
if board, lodging or other advantages were furnished in addition to-
wages, state nature and estimated weekly value
North Dakota
Will employee be off the job for five or more consecutive days?
" Time employee left work due to this injury
Time workday began on the day of in jury
If employee has not returned to work, estimate date of return
Employee's gross lota! .earnings forth© past 52 weeks
if employee has returned lo work, at what wage?
If fatal, name and address of nearest relative
Texas
Federal Tax ID Number
Does the employee speak English? (i if no; specify language)
Employee’s mailing county
If married, spouse's name
013020 WUNTDG98
POLICY# CX10568264
URBAN MOVING SYSTEMS, INC.
312 PROVONIA AVENUE #1
JERSEY CITY, NJ 07302
•> AGENT: A.E GOETTELMANN. & CO.
# 31001540 -
Prems Bldg
No. No. Street
001 001 445 WEST 50TH STREET
(LIABILITY ONLY)
002 001 3 18TH STREET
City County St Zip
NEW YORK NY 10019
WEEHAWKEN NJ 07087
HUDSON
l
i
i
i
i
i
i
JUL 12 2001 3:55PM 1^
POLICY NUMBER: CX10568264
-FORM SCHEDULE
LASERJET 3200
COMMERCIAL
Forms and Endorsements applying to this Coverage Part and made a part of
policy at time of issue:
FORMS APPLICABLE TO ALL PREMISES AND COVERAGES ’ '
Form
Edition
FORM SCHP
12
96
FORM SCHL
12
96
IL0017
11
85
IL0023
04
98
IL0183
04
98
IL0208
04
98
IL0268
07
00
IL0935
08
98
Description
PROPERTY FORMS SCHEDULE
LIABILITY FORMS SCHEDULE
COMMON POLICY CONDITIONS
NUCLEAR ENERGY LIABILITY EXCLUSION ENDT
NEW YORK CHANGES -FRAUD
NEW JERSEY CHANGES -CANCELLATION & NONRENEWAL
NEW YORK CHANGES - CANCELLATION & NONRENEWAL
EXCLUSION OF CERTAIN COMPUTER RELATED LOSSES
c-
ALL IKFORKATION CONTAINED
HEREIN IS UNCLASSIFIED
DATE 07-30-2010 BY UC60322LP/PLJ/CC
*
p. 22
POLICY
this
Page 1 of 1
JUL 12 2001 3:55PM
LASERJET 3200
POLICY NUMBER: CXI 05 68264
■FORM SCHEDULE
p. 23
COMMERCIAL PROPERTY
Forms and Endorsements applying to this Coverage Part and made a part of this
policy at time of issue:
FORMS APPLICABLE TO ALL PREMISES AND COVERAGES
Form.
Edition Description
CP0010
CP0090
IL0003
06 95 BUILDING AND PERSONAL PROPERTY COV FORM
07 88 COMMERCIAL PROPERTY CONDITIONS
04 98 CALCULATION OF PREMIUM
FORMS APPLICABLE TO SPECIFIC PREMISES AND COVERAGES
Form .Edition Description
CP1030 06 95 CAUSES OF LOSS-SPECIAL FORM
PREMS 002 BLDG 001 YOUR PERSONAL PROPERTY
ALL IKFORKATION CONTAINED
HEREIN .IS UNCLASSIFIED
DATE 07-30-2010 BY UC60322LP/PLJ/CC
Page 1 of 1
JUL 12 2Q0 X 3:55PM
p. 24
POLICY NUMBER: CX10568264
.FORM SCHEDULE 4
LASERJET 3200
COMMERCIAL LIABILITY
Forms and Endorsements applying to this Coverage- Part . and made a part of this
. policy at time of issue :
FORMS APPLICABLE* TO ALL PREMISES AND COVERAGES
Q
Form
CG0001
CG0001
CG0104
CG0163
CG2147
CG2147
CG2149
CG2160
CG2620
• CG2621
CG2624
CG2649
IL0003
IL0021
IL0021
U9935
Edition
01 96
07 98
04 97
07 98
07 98
10 93
07 98
09 98
10.93
10 91
08 92
06 99
04 98
04 98
11 85
07 91
Description
COMML GENERAL LIABILITY COV FM (OCCURRENCE)
COMM GEN LIAB COV FORM- OCCUR VERSION
NEW YORK CHANGES -PREMIUM AUDIT
NY CHGES COMML GENL LIAB COVERAGE FORM-
EMPLOYMENT- RELATED PRACTICES EXCLUSION
EMPLOYMENT -RELATED PRACTICES EXCLUSION
TOTAL POLLUTION EXCLUSION ENDORSEMENT
EXCL-YR 2000 COMPUTER-RELATED/ELECTRONIC PROB
NJ CHANGES - LOSS INFORMATION
NY CHANGES - TRANSFOER OF DUTIES WHEN A LIMIT
NY CHANGES - LEGAL ACTION AGAINST US
NJ CHGES -COV FO LIABILITY FOR HAZARDS OF LEAD
CALCULATION OF PREMIUM
NUCLEAR ENERGY LIABILITY EXCL ENDT
NUCLEAR ENERGY LIABILITY EXCL ENDT
COMMERCIAL GENERAL LIABILITY
ALL INFORMATION CONTAINED .
HEREIN IS UNCLASSIFIED
DATE 07-30-2010 BY UC60322LP/PLJ/CC
Page 1 of 1
■JUL 12 2001 3 : 56PM
LASERJET 3200
p. 26
!
Insured Name: URBAN MOVING SYSTEMS INC
Policy Number: 6S59 UB 688X6573
Policy Term: 09/1 8/2000 - 09/1 8/2001
NJ 09/18/2000 001 01
ANNUALIZED PAYROLL EXPOSURES
FOR YEAR ENDED 12/31/00
FURNITURE MOVING & STORAGE.
8293 01 DRIVERS
8810 02 CLERICAL OFFICE EMPLOYEES NOC
kLL IHF0RHATI0N COIJTAIHEB
^EEEIH IS OTC LASS I FIED
PATE 07-30-2010 BY UC60322LP/PLJ/CC
I
i
I
!
I
i
(Rev. 08-28-2000)
' ' I
DATE: 07-30-20^4^^
CLASSIFIED ET lMp22LP/PLJ/CC
PEAS 01: 1.4 (C) '* ft
DECLASSIFY 01: 07-30-2035
ALL UFO!
* HERE II I
i WHERE SHO'
H C01TAIHED
LASSIFIED EXCEPT
OTHERWISE
FEDERAL BUREAU OF INVESTIGATION
Precedence : ROUTINE
To : Newark
Date: 09/17/2001
Attn: IMA (Rotor) , Squad C-9
From:
Newark
C-9
Contac
b2
b 6
b7C
bl
Approved B^ }ll
I
Drafted By:
Case ID #:
Title:
Synopsis: ^^^^.equest sub-files for to captioned investigation.
Deriv^d/From : G-3
Declassify On: XI
Details: 09/14/2001, Newark Division, with the
assistance or the New York Office (NYO) , initiated an
investigation predicated upon the detention of five (5) Israeli
Nationals who may have possessed information about the terrorist
incident targeting the "Twin Towers" of New York City's World
Trade Center (WTC) .
, r .v\J*/he following sub-files are requested to serve
as repositories for the investigative information developed on
the five (5) Israeli Nationals described herein:
Sub-file A
B
C
D
E
be
hlC
Investigation at Newark continues ,
,v
DA’
class;
REASON: !.4( C
DECLASS]
ALOlP0RMAnpNC(
HERpilSWW^ElED
WHERESHOWN OTHERS
NED V
EXCEPT
bl
^ ‘ V
l - 1
(Rev. 08-28-2000)
DATE: 07-30-2010
CLASSIFIED BY IJCS0322LP/PLJ/C
PEAS OH: 1.4 (C)
DECLASSIFY OH: 07-30-2035
ALL .^INFORMATION CONTAINED
HERE II IS UNCLASSIFIED EXCEPT
WHERE SHOOT OTHERWISE
se^(et
FEDERAL BUREAU OF INVESTIGATION
Precedence : ROUTINE
To : Newark
From: Newark
C-9
Contact : SA
Date: 09/17/2001
Attn: Squad C-9
Approved By
Drafted By: |
Case ID #:
Title: 1
jnding)]
Synopsis :
Report I
obtained.
DerivedNJJ'rom : G-3
Declassify On: XI
Administrative: (^^)The attached
Iwere obtained
Details: On 09/14/2001, Newark Division, with the
assistance oiFthe New York Office (NYO) , initiated an
investigation predicated upon the detention of five (5) Israeli
Nationals who may have possessed information about the terrorist
incident targeting the "Twin Towers" of New York City's World
Trade Center (WTC) .
(fiQj^The attached | Iwere obtained pursuant
to a criminal subpoena served on
(j^lOAccording to the display windows of the
telephones, the following telephone numbers correspond to the
following individuals :
CLASSIFEEBte^fc^J
REASONO^CO )&f'
DECLASSIFY ON; W
AHrtNFORMATiOM COm&mZfT'
FPT
FD-302 (Rev. 10-6-95)
DATE: 07-30-2010
CLASSIFIED BY UC60322LP/PLJ/CC
REASON: 1.4 (c)
DECLASSIFY OH: 07-30-2035
ALL INFORMATION CONTAINED
HEREIN IS UNCLASSIFIED EXCEPT
WHERE SHOWN OTHERWISE
;
FEDERAL BUREAU OF INVESTIGATION
Date of transcription 09/ 12 /2001
born I I of
| Union City, New Jersey, was interviewed at her
residence. EFter being advised of the identity of the interviewing
agent and the nature of the interview, she provided the following
information. GO
Aft er being sho wn nu mbered photograp hs o f I
~l born I I (#1) , I — - I hoyi I I (#2 ) ,
1 born I I (#3 ) , | Iborn I
(#4) and | I bp rn l I (#5) .1 | stated she
recognized rne S4 | I photograph. I I believed she .
recognized from standing in line for the bus at the Port
Authority in New York, New York. GO
Lead covered for control number 1148.
CLASSIFIEDMr^
REASON:
BECtASSlFYON:.
ALL INFORMATION CQNTAfWED
HEREIN jSu5o&^i|DEXC£PT
investigation on 09/12/2001 at Union cit - '
New Jersey
This document contains neither recommendations nor conclusion
it and its contents are not to be distributed outside your agencj
nd is loaned to your agency
w FD-302 (Rev. 10-6-95)
ALL INFORMATION CONTAINED
HE PE 1 1 IS UNCLASSIFIED EXCEPT
WHERE SHOOT OTHERWISE
DATE: 07-30-2010
CLASSIFIED BY UC60322LP/PLJ/CC
PEAS ON: 1, 4 i] C )
DECLASSIFY ON: 07-30-2035
- 1 -
;STIGATION
Date of transcription 09/11/2001
[
On 09/1 1/01, Special Agents (SA)
and
interviewed Police Officer
] of the F ederal Bureau of Investigation (FBI) ,
East Rutherford Police
stated that while assigned to a traffic detail,
diver ting traf fic from Route 3 East to Route 120 North and Route 3
West , |~ “[ observed a white C jlhevrole^ van traveling slower than
other vehicle on Route 3 East .
recalled a message
transmitted by dispatch of a national broadcast to be on the
lookout for a white Chevrolet van bearing NJ registr ation JYJ 13Y,
related to the terro rist attack earlier in th e day. I I
immediately informed | | of the possibility
that he has observed the white CHEVROLET van wanted in connection
of the terrorists attack.
stopped the vehicle al ong with
and
the occupants from the vehicle. L
occupants were transported to the State Police facilities ins ide
the Meadow land s Sports Complex by New Jersey Stat e Tro opers : f
DOB: f
£r
'^r white male. CuT
white ma le
do:
1 whi te ma le; f
77
Jwh
DOB: t
ite male; and
DOB: T
I white male;
T5CBT
J , , advised that prior to the S tate Troo pers
•j transporting the occupants to their facility. I I was told by
"We are Israeli. We are not your problem. Your
] then told
the incident
toid r
. " tv&
advised that he will write a detailed Police
reported for his department documenting the incident .
b 6
b7C
Department, East Rutherford^ New Jersey, who provided the following
information: GO
lwho assisted in removing
"J advised that the following
]
problems are our problems. The Palestinians are the problem."
| "We were on the west side highway during
ALL INFORMATION CONJfi
HEREIN ISONeU^FtED EXCEPT
WHERE SHOWNOTRERWLSE
Investigation on 9/ 11 / 0 1
at NEW JERSEY
lb 7 A
Date dictated 9 / 1 1 / 0 1
SA
* , f r i - i :
bl
This document contains neither recommendations nor conclusions of th^
it and its contents are not to be distributed outside your agency.
ifei
EAST RUTHERFORD POLICE DEPARTMENT
312 Grove Street
East Rutherford, New Jersey 07073
Telephone
201-438-0165
[X] PRELIMINARY POLICE REPORT
[ ] SUPPLEMENTAL REPORT
CSRR DATE TIME DAY LOCATION
014157 09/11/01 1556 Tue Rt-3 East
Service Rd. Mile 7.9
Nature of Report
Police Information
dPLAINANT LN PO-I I FN I I DO]
This officer was on special detail at the above location diverting
traffic from further travel on Rt 3 east re-routing the traffic north on Rtl20
and 3 west .
While diverting traffic, this officer was informed by dispatch of a
national broadcast related to the terrorist attack earlier in the day. The
information relayed was to be on the look out for a 2000 chevy van color white
NJ registration JYJ13Y occupied with approximately 3 or more individuals
(unclear as to male or female) . A short time later this officer observed a van
traveling quite slower than the rest of traffic east towards me on the service
road that appeared t o be a newer model chevy with at least two occupants . I
immediately informed | | (The OIC at the scene) of the possibility of a
match on the vehicle. As this officer approached the vehicle I did not observe
a front license plate.
I went to the rear of the vehicle and observed the license plate (NJ
JRJ13Y) I felt that the one letter difference in the plate could have been a
mistake and requested a confirmation. The return transmission revealed the
plate on the van matched the broadcast so at this time I returned to the
driver door and requested the driver to stop the vehicle and exit . The Driver
did not immediately exit th© vehicle and was asked several more times but he
appeared to be fumbling with a black leather fanny pouch type of bag. This
officer then physically removed him. I I removed the passenger and one
othe r passenger from the passenger si de of the van and with minor assistance
from | | the other two occupants were removed
placed on the grass off to the shoulder and this officer read all five
individuals their miranda rights. The van was secured and headquarters was
requested to immediately notify the County Bomb Squad and FBI of the
situation.
All occupants were transported to the state police facilities inside the
Meadowlands sports complex bv State Troopers t o await the arriv al of the FBI.
The oc cupants were ( Driver) | w/m dob I . l addressess
given: | ( Brooklyn NY a nd I I Isr ael wear ing blue jeans torn
knees a nd a gray and black shirt. I 1 w/ m dob I I
I | Miami Beach Fl 33139 Wearing jean overalls., I I no
address g iven/ wearing a pink shirt and blue ieans. l I w/m dob
I [ No address given and uncert ain of clothing description but indiv idual
was holding a n American Expres s Card j I w/m
dob I I of I l Manhatten NY I I only personal
belongings were a pack of Cigarettes and black sunglasses . I am not sure to
the position of the other passengers. rQHTA TW ^ *^ v -
Report of P0-
Officer in Charge
* Chief of Police *
John R. LaGreca
CSRR
014157
DATE
09/11/01
EAST RUTHERFORD POLICE. DEPARTMENT
312 Grove Street
East Rutherford, New Jersey 07073 Telephone
201-438-0165
[x] PRELIMINARY POLICE REPORT
[ ] SUPPLEMENTAL REPORT
TIME DAY LOCATION
L 1556 Tue Rt 3 East
Service Rd #7 . 9
Nature of Report
Police Information
COMPLAINANT
Address
LN PO-
Prior to the transportation to the State Police facilities this officer
was told without question by the driver "We are Israeli, We are not your
problem. Your prob lems are our proble ms. The Palestinians are the problem."
I was also told by| | "We were on the west side highway during
the incident . " The black bag that the driver was fumbling with contained all
of his belonging s (see attached Receipt from the FBI for its contents) .
I T was in possession of a white sock like sack filled with $4,70'
in cash ( see attached receipt from FBI) .
This officer did not speak to the Special Agent in charge Kevin Donovan and
there were many other agen ts i nvolved in the investigation. Two o f which were
I I andl I
Report of PCH
Officer in Charge
EAST RUTHERFORD POLICE. DEPARTMENT
312 Grove Street
East Rutherford, New Jersey 07073
Telephone
201-438-0165
[ ] PRELIMINARY POLICE REPORT
[X] SUPPLEMENTAL REPORT
CSRR DATE TIME DAY LOCATION
014157 09/11/01 1556 Tue Rt-3
South-Service-Rd
Nature of Report
Police- Information
While on a traffic detail diverting traffi c to Rt. 1 20 as Rt . 3 east was
closed, we were informed by our desk officer PO that there was a
broadcast looking for a 2000 white Chevy van, NJ reg. JYJ- 13Y, occupied by at
least 3 people. After a short period of time, PO who was on the
traffic detail with me, advised me that a van which was slowly approaching us
matches that description of the broadcast. PO | approached the driver's
side of the vehicle and I approached the passenger side. I was able to see at
least 4 people in the van, two in the front and two in the back. Officer
| read the piste num ber and I contacted the desk for confirmation on the
plate number. PO 1 advised me that the plate #, NJ reg. JRJ-13Y is one
number off. He then contacted Hq and then it was confirmed that the plate on
the vehi cle was i n fact the plate that the FBI had stated in the broadcast.
While PO was removing the driver from the vehicle, I removed the^ front
seat passenger and one of the rear seat passengers . As I was _ removing the
front seat passenger he s tated " we're Isre ali". He was identified, via Isreal
passport as I W/M Dob I | of Isreal. He advised me that they
were on their way to | | in Brooklyn where they are sta ying w ith a
roommate . He did not have the exact address . I I and I I
| arrived at the scene. All five males were handcuffed and PO I
read them their miranda warnings. All five spoke and understood English and
they acknowledged their understanding of miranda. _ *
Bergen Cou nty Bomb Squad, State P olice and FBI notified. The driver of
the vehicle was | IW/M Dob I I of | . ■ I Brooklyn,
NY. The rear passengers were : I [ W/M Dob I o£ I 1
I I Miami Bea ch, FL (he was wearing blue jean overalls) ; | | W/M
Dob I l(no address given - wea ring a pink shirt and blue Jeans);
andf I W/M Dob | | of I I Manhatten, NY.
FBI agents responded and took over the scene. All five were seperately
transported to the State Police facilities in the Meadowlands Sports Complex
by State Troopers. Further investigation by the FBI.
ftT.T. INFORMATION TONTA3NED
Report of
Officer in Charge
-A- -A* -A* A A* A* A- A A A A A A A A A A A A A A A A' A: A* A -A*
I..APD---90230 09/3. 1/0:1. 1615
S T A T E l.-J I D E B R 0 A D C A S I * * * a a a a -a a a -a -a a a- a a -a a a a a a a -a * a
AM . NJN8P0D00
13:10 09/11/2001 05286-
13:10 09/11/2001 06032 MJ
TXT ( A P >
REQUEST NATIONAL BROADCAST
TO: A L L R E C E I V E R S
RE: B 0 L 0
VEHICLE POSSIBLY RELATED TO NYC TERROR I SI
ATTACK * * CORRECTION ON REGISTRATION
A WHITE 2000 CHEVROLET- VAN WITH NEW JERSEY REG/JRJ3.3/ W1 ( H
"URBAN MOVING SYSTEMS" SIGN ON BACK WAS -SEEN A'i i HE L.I.BLRl'r
STATE PARK.. JERSEY CITY N.J. AT THE TIME OF THE PIRSt J.MPAC( 01-
A JET AIRLINER INTO THE WORLD TRADE CENTER. THREE INDIVIDUALS
WITH THE VAN WERE SEEN CELEBRATING AFTER THE INITIAL -IMPACT;. AND
SUBSEQUENT EXPLOSION.
, '
.13,1, NEWARK FIELD OFFICE IS REQUESTING THAT IF THE VAN IS
.0 GATED , HOLD FOR PRINTS AND DETAIN INDIVIDUAL
' 4 1 T H ANY INFORMATION
* N-.J8P OPERATIONAL DISPATCH NJNSPOOOO JG
-a--a- MSG ROUTED TO CRTS FROM NJSP OPE
CONTACT 8. A
1606ET
■bo
b7C
MSG ROUTED TO CRTS
'ROM NJSP OPERATIONAL DISPATCH
-a- 09/11/01
161
ALL INFORMATION’ CONTAINED*
r
i
NEW JERSEY
’ACTlIlGDinCCTOR
iiviSIDII Of [.IQTOf] CHICLES,
LEASED VEHICLE REGISTRATION^
:rrs-
pSxff DL;34090 300111 10300
H TV NY 11530 DUPLICATE PT:PA
.“i FEE 5.00 «0012j»7
r po BOX 83
GARDEN CITY NY 11530
' - MOTOR VEHICLE SERVICES
A RECEIPT DOCUMENT ONLY
Is HOV 2001 VIN:
MAKE: CHE
YEAR:2000
TYPE: VAN
MODEL:
COLOR :WT
PT:PA
AX: 2
GW: 5000
EQ: 5000
RE6CD : 15
1GCEG15W4Y1142815
REG D : 5,
FD REG:
POST AUDIT;
PLATE FEE:
TOTAL: 5.00
AR BG20012390037
IV2A (1*96)
(STATE)
INSURANCE IDENTIFICATION CARD
COMPANY NUMBER
111
POLICY NUMBER
CABIND08C6C1
COMPANY
EMPIRE FIRE & MARINE INS CO
EFFECTIVE DATE EXPIRATION DATE
08/06/2001 10/06/2001
YEAR MAKE/MODEL VEHICLE IDENTIFICATION NUMBER
2000 . GMC/VAN 1GCEG15W4Y1142815
ASENOY/COMPANY ISSUING CARD
DeBellls Insurance Agency, Inc.
492 Franklin Avenue (973)661-1500
Nutlsy, NJ 07110
y.\
INSURED
i *
URBAN MOVING SYSTEMS INC
3 18TH STREET
WEEHAWKEN, NJ 07087
SEE IMPORTANT NOTICE ON REVERSE SIDE
U
'FD-597 (Rev 8-11-94)
File #■
UNITED STATES DEPARTMENT OF JUSTICE
FEDERAL BUREAU OF INVESTIGATION
Receipt for Property Received/Returned/Released/Seized
On (date)
(Name)
(Street Address)_
(City) £
<7- // - 0 !
itejn(s) listed below were:
Received From
□ Returned To
g Released To
g Seized
tint lea
CA-J-Ai
6s? t fa&J5
r 5 (4 < * fa fat'?? * 3 *-. f if Co ?b
fa j£s . .£ AtS Ce./rJT'
CO
sass&^
3 /'V
Received By
(Signature)
/ Fft-597 (Rev 8-11-94)
Page
it •
UNITED STATES DEPARTMENT OF JUSTICE
FEDERAL BUREAU OF INVESTIGATION
Receipt for Property Received/Returned/Released/Seized
J of — j-
File # P - N y
On (date) Cf\
I Ll I
(Name)_
(Street Address) I
Job
hlC
itepi(s) listed below were:
sq R eceived From
□ Returned To
□ Released To
□ Seized
(City) At V
Description of Item(s): 1
J2j 6 U \ o L
p/^Kj/vy.
* ^QU~A)M>N^ £.
-I — &ncuk£&
A .2_— 6 -fc. (
i
f ^
~ \/Ua C/vtO ^
IV r /o aaJT
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— T. U1±LZC(L£. CAn-O
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k m&jdl i
m $ U1 teziysi a. dL ILL i
■j. W . $ 26 - /2MA&Z ZtlL- Q^L
A l f Mbu^.o.
fJSL E^ORa/LarioN COWTA TOtm
HEREIN
-DATE
JUzs: — £LX
3DH'£S BNCLASSIEIED , / /
A
Received By:
L
"'^"Received From:
□
(Signature)
FD-302 (Rev. 10-6-95)
DATE: 07-30-2010
CLASSIFIED BY UC60322LP/FLJ/CC
PEAS 01: 1.4 ( C)
DECLASSIFY 01: 07-30-2035
FEDERAL BUREAU OF INVESTIGATION
ALL INFORMATION CONTAINED
HEREIN IS UNCLASSIFIED EXCEPT
WHERE SHOOT OTHERWISE
Date of transcription
09/14/2001
In connection with a canvass conducted by the below-. .
referenced Special Agent at the apartment building located at | |
| Union City, NJ, to identify individuals reporting
any unusual activity around the apartment building over the prior
few days, the following interview was conducted: fr)
date of birth
_ I Union City) NJ, telephone |
was interviewed. After' being advised of the official
identity of the interviewing agent and the purpose of the interview
she provided the following information: *)
The morning of the interview, a white van was parked in
the rear parking lot of the apartment complex. The van was white
and had no windows on the sides. It appeared to be a utility van
for an electric company. The name of the company, since forgotten,
was in red letters on the van. (jt)
Usually, utility or service vehicles at the complex
building parked in the front . This vehicle was parked in the back
which is why it came to the interviewee's attention. It seemed out
of place. No further information was available . (.u.)
This report is being submitted in connection with Lead NK1148.CcO
ALL INFORMATION CONTAINED
HEREIN IS UNCL^SIFIED EXCEPT
WHERE SHOWN OTHERWISE
CLASSIFIED BY:
REASO
gEGfcSSSiFi ON:
investigation on 09/11/2001 at Union City, NJ
Date dictated 09/14/20 0.1
by *SA
This document contains neither recommendations nor conclusions of the.TjE
it and its contents are n^t to Be distributed outside your agency. I
FEDERAL- BUREAU OF INVESTIGATION
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